U UNIVERSITY OF CINCINNATI
Date: May 26, 2009
I, Elizabeth Grace Wehri , hereby submit this original work as part of the requirements for the degree of:
Master of Arts in Anthropology
It is entitled: A Classification System of Osteomyelitis for Historic Skeletal Remains:
An Assessment of Civil War Soldier Amputees
Student Signature: Elizabeth Wehri
This work and its defense approved by:
Committee Chair: Alan P. Sullivan Anthony J. Perzigian MariaTeresa A. Tersigni-Tarant
Approval of the electronic document:
I have reviewed the Thesis/Dissertation in its final electronic format and certify that it is an accurate copy of the document reviewed and approved by the committee.
Committee Chair signature: Alan P. Sullivan A Classification System of Osteomyelitis for Historic Skeletal Remains: An Assessment of Civil War Soldier Amputees
A thesis submitted to the
Division of Graduate Studies and Advanced Research
of the University of Cincinnati
in partial fulfillment of the
requirements for the degree of
MASTER OF ARTS
in the Department of Anthropology
of the McMicken College of Arts and Sciences
2009
by
Elizabeth G. Wehri
B.A., Purdue University, 2007
Committee: Alan P. Sullivan III (Chair) Anthony J. Perzigian MariaTeresa A. Tersigni- Tarrant (ex-officio) ABSTRACT
Osteomyelitis is a pus-producing infection caused by the presence of bacteria, such as
Staphylococcus aureus, that specifically affects the endosteal surface of bone. Although this disease can be found in prehistoric and historic populations, one ubiquitous system for descriptive classification has not been developed for use on skeletal remains. This research utilizes the long bones from Civil War soldier amputees with evidence of osteomyelitis, housed at the National Museum of Health and Medicine in Washington D.C., to develop a classification method for use on skeletal collections to assess the characteristics of osteomyelitis. In total, 77 long bone specimens (including humeri, radii, ulnae, femora, tibiae and fibulae) were examined.
Three categories, Etiology, Severity and Duration, were used to both classify and describe the osteomyelitis presented in each case. The first category, Etiology, describes the origin of the infection by determining whether the osteomyelitis is “Exogenous” or “Hematogenous”. The second category, Severity, is divided into “Minor”, “Moderate,” and “Severe” Hyperostosis. The final descriptive category, Duration, determines whether the infection is “Acute” or “Chronic” based upon information gathered from medical records. The Wehri classification system of osteomyelitis can be readily applied to collections of skeletal remains, unlike most other methods of classifying osteomyelitis, because it provides specific morphological traits for each category, thereby removing the vague nature of other systems.
i ii Acknowledgements
I would like to thank the Department of Anthropology and University of Cincinnati for giving me the opportunity to continue my education in Physical Anthropology. My experience at UC has been enlightening. Thank you to my committee members, Dr. Alan Sullivan,
Dr.Anthony Perzigian and Dr. MariaTeresa Tersigni-Tarrant, for their input and diligent editing of this thesis. I would also like to thank Dr. Alan Sullivan, Dr. Jeffrey Jacobson and Dr.
MariaTeresa Tersigni, for their donation of tools used during this research project. Thank you for understanding that it is difficult for a poor grad student to subsidize all the materials needed to undertake proper research.
I would also like to thank the Taft Research Center for granting me the Graduate Student
Enrichment Award. These funds were essential to reaching my research destination and my daily living expenses during my data collection period.
Thank you to the National Museum of Health and Medicine (and the Armed Forces
Institute of Pathology) for allowing me access to the skeletal collection used for this research, as well as, a work area in which I was able to perform daily data collection.
There are many special people in my life which require recognition as well. All of these individuals require credit for final product of this thesis. The many tasks provided by these individuals range from editing to moral support.
Dr. Tersigni aka Dr. Tersigni-Tarrant, Dr. MT, Mrs. Tarrant, my rightful committee chair, I can’t even begin to express how much I appreciate all that you have done for me the past two years. You have truly gone above and beyond what is expected of most professors. I could not have imagined a better mentor or friend than you. I value your intelligence in all areas, specifically physical anthropology, and appreciate all that you have taught me while being at UC
iii and after. I learned more from you about this field in the past two years, than I think I learned in the entirety of my undergraduate career. Thank you for always being there when I was over stressed or freaking out about my thesis or everyday issues (although I think the freaking out was mostly done by Jess!). Thank you for lighting a fire under my tail when I slacked on both my thesis and class work. If you hadn’t been such a slave driver, I would not have finished this project in such a timely manner. Finally, thank you for dedicating yourself to your students
(specifically Jessica and Myself). You could have very easily passed our theses to someone else and made your life much less stressful. On that note, don’t relax just yet. I will need you for my dissertation. Thank you again and again!
Dr. Sullivan, thank you so much for taking me in as your student when I was a little grad student orphan. I appreciate all the work you have put into this thesis. I know it was trying at times, especially when discussing statistics with me. This research project is better because you were on my committee and were a touch critic. You can now officially add one more individual to your very short list of people you have not made cry!
Jessica-Fireman-Juarez, I don’t think I could have made it to this point with out you.
Things have really been a rollercoaster for us through this program (as you well know) and I am glad that you were the one with whom it was shared. I value your friendship and scholarly abilities more than you could know! Thanks for patiently reading and editing my chapters, when
I know you had your own to work on as well. I know those times were not really breaks from your own thesis. I will miss you greatly after we leave, but look forward to our many years of friendship (may we be far or near). Try not to be a spazz at your new program. I know you won’t find a better cubby buddy there!!
iv Franklin Damann and Brian Spatola: Gentlemen, it was truly a pleasure working with the both of you. Your expertise on this collection was essential to my data collection. I know I could not have survived the process of research with out your intelligent conversation and sarcastic wit to entertain me. I do hope that there is a chance for me to work with the both of you in the future.
Erin Gill aka Er-Bear: I didn’t imagine that I would find such a friend as you during my time at UC! You have made these years amazingly fun and entertaining. Thanks for always being there to distract me from my work and forcing me to get off my butt to go to the gym. I am sure that the Anthropology Dept. will not be the same without the “Blondes” to confuse people. I truly consider you one of my best friends and will miss you immensely once we move away from Cincinnasty.
I would also like to thank Kevin, Marianne and Angie for their amazing friendship and continued support of my project. I don’t think I could have survived grad school without any of you. I know we will all be lifelong friends and I am truly thankful for that.
Last, but not least, I would like to thank my family for their moral and financial support throughout the whole process of grad school and the writing of this thesis. I am very lucky to have a family that continuously supports my passion. There is never a doubt that you all are proud of my accomplishments and that means the world to me. Thank you, Thank you Thank you! I love you all!
v Table of Contents Abstract…………………………………………………………………………………………..i
Acknowledgements……………………………………………………………………………..iii
List of Appendices……………………………………………………………………….……………..viii
List of Figures…………………………………………………………………….…………………….ix
List of Tables……………………………………………………………………….…………….x
Chapter 1: Introduction……………………………………………………………………………1
Chapter 2: Medical History of the Civil War…………………………………………….………..3
Union and Confederate Medical Departments…………………………………………..…..……3
The Doctors…………………………………………………………………………...... ………6
Disease and Illness………..………………………………………………..………….…….……8
Surgery ………………………………………………………………………………… .………..9
Amputations……………………..………………………………………..…………… ….……12
Social Ramifications of Amputation ……………………………………..……………… ….…14
Chapter 3: BonBiology…………………………………………………………………………..15
Bone Maintenance Cells and Composition…………………………………………………… .15
Anatomy of Bone………………………………………………………………………………....17
Skeletal Development……………………………………………………………………………19
Modeling and Remodeling…………………………………………………………..…. ………20
Chapter 4: Osteomyelitis……………………………………………………………………..…..25
Hematogenous Osteomyelitis………………………………………………………...………….25
Clinical Development…………………………………………………………………...……….27
Exogenous Osteomyelitis………………………………………………………..………………30
Chronic vs. Acute ……………………………………………………………….………………31
vi Historic Treatment of Osteomyelitis………………………………………………….…………32
Clinical Classification of Osteomyelitis…………………………………………………………32
Chapter 5: Materials and Methods……………………………………….………………………35
Specimen Selection……………………………………………………………………………...35
Gross Visual Analysis………………………………………………………...…………………36
Documentation…………………………………………………………….…………………….39
Data Compilation………………………………………………………………………………..40
Statistical Analysis…………………………………………………..…………………………..40
Chapter 6: Results and Discussion………………………………………………………..……..41
Results………………………………………………………………………..………………….41
Discussion……………………………………………………………………………………….42
Summary……………………………………………………………….………………………..45
Chapter 7: Conclusions………………………………………….……………………………….46
References Cited…………………………………………………..……………………………. 49
Appendix A…………………………………………………………………………...………….51
Appendix B……………………………………………………………………………………....53
Appendix C………………………………………………………………………………………54
Appendix D………………………………………………………………………………………58
vii List of Appendices
Appendix A: Osteomyelitis Recording Form…………………………………………………51
Appendix B: Osteomyelitis Categorization Description…………………………………….. 53
Appendix C: Specimen Information……………………………………………………….….54
Appendix D: Data results………………………………………………………………..……58
viii List of Figures Chapter 2: Figure 2.1: Wounding Mechanisms of the Civil War……………………………………………………………….10
Chapter 3:
Figure 3.1: Bone Maintenance Cells………………………………………………………………………...………17
Figure 3.2: Long and Short Bones……………………………………………………………………………………18
Figure 3.3: Flat Bones………………………………………………………………………………………………..18
Figure 3.4: Irregular Bones…………………………………………………………………..………………………18
Figure 3.5: Endochondral Ossification……………………………………………………….………………………20
Figure 3.6: Directional Growth during Endochondral Ossification………………………………………..…………21
Figure 3.7: Woven and Lamellar Bone……………………………………………………………...………………..23
Figure 3.8: Compact and Trabecular Bone……………………………………………………………………...……24
Figure 3.9: Osteon and Volkmann’s Canal…………………………………………………………...………………24
Chapter 4:
Figure 4.1: Blood flow with in Bone……………………………………..…………………………………………..27
Figure 4.2: Sequestrum and Involucrum……………………………………..……………………………………….29
Figure 4.3: Cloacae and Fistula………………………………………………..……………………………………..29
Chapter 5:
Figure 5.1: Hematogenous Osteomyelitis Example………………………………………………………….……….37
Figure 5.2: Exogenous Osteomyelitis Example………………………………………………………...…………….27
Figure 5.3: Minor Hyperostosis Example…………………………………………………………………………….38
Figure 5.4: Moderate Hyperostosis Example………………………………………………….……………………..39
Figure 5.5: Severe Hyperostosis Example……………………………………………………..…………………….39
Chapter 6:
Figure 6.1: Frequency of Severity……………………………………………………………………………………41
Figure 6.2: Frequency of Etiology………………………………………………………………...…………………41
Figure 6.3 Frequency of Duration……………………………………………………………………………………42
ix List of Tables Chapter 5:
Table 5.1: Levels of Severity of Hyperostosis in Osteomyelitis………………………………………….………….38
Chapter 6:
Table 6.1: Chi-squared test for all specimens……………………………………………………………………..….43
Table 6.2: Chi-squared test with undetermined specimens removed………………………………………………....43
x Chapter 1: Introduction
Disease is a common occurrence in human populations, and is a subject of much interest in physical anthropology. Paleopathology is a sub-field of physical anthropology in which researchers attempt to learn about the lifestyles and medical practices of historic and prehistoric populations through the study of ancient disease and its effects on past populations.
Some of the greatest minds in paleopatholgy have determined that the one of the most important issues within the field is the indistinct and rough descriptions and methods that are being used to examine the pathological disorders present in human skeletal remains. According to Donald J. Ortner and Arthur C. Aufderheide “Our descriptive methodology and classificatory system are major barriers to comparative research” (1991: 1). A similar sentiment has been put forth by Mary Lucas Powell and Della Collins Cook in their book, The Myths of Syphilis: The
Natural History of Treponematosis in North America, when they said “If what we are doing in paleopathology is science, we must set out objective criteria for identifying diseases in ancient human remains and make our identification procedures explicit” (2005:42).
One such pathological disorder that is in need of a more explicit methodological identification process is osteomyelitis. Osteomyelitis, which is discussed in further detail in
Chapter 4, is a pus-producing infection of the marrow cavity of the bone shaft. The infection occurs on the inside surface of the bone and is caused by the presence of abnormal pus- producing bacteria (Adler, 2000; Aufderheide and Martin, 1998; Ortner, 2003; Rockwood &
Green, 1984).
The purpose of this research is to develop a classificatory system for osteomyelitis, as well as determine the relevance of the morphological feature criteria set forth for each category within the system. Two hypotheses were tested in order to determine the relevance of the
1 categories within system and the morphological features describing each sub-category. The first hypothesis being tested is that there is not a relationship between Severity, Etiology and
Duration. The second hypothesis being tested is that there is a relationship between the level of
Severity and the morphological features of involucrum, sequestrum and cloacae.
The research in this thesis was performed on the AC2 skeletal collection of Civil War soldiers at the National Museum of Health and Medicine in Washington D.C. From the collection of Civil War soldier remains, amputees were chosen due to the high probability of various types of osteomyelitis being present in this subset of the nineteenth century population.
The medical practices during the Civil War also influenced the selection of the specimens and allowed for a higher probability of osteomyelitis in amputees.
Chapter 2 is an in depth description of the medical practices during the Civil War and the outcomes of such medical care. In order to more deeply understand the disease and its effect on human bone, background information is included on both bone biology and osteomyelitis in
Chapters 3 and 4.
2 Chapter 2: Medical History of the Civil War
The exhilaration of battle dissipates under the load of fever, diarrhea, maggots, blood, dysentery, blindness, pain, pus and putrefaction. -Frank R. Freemon, Gangrene and Glory
War has been depicted time and again as a glorious display of heroism and righteousness in a world of evil actions and wrong doers. These depictions mainly focus on the winners, the losers and the battles occurring between them. Almost always forgotten is the fact that war does not stop once a battle is over; instead, most unpleasantness ensues in the aftermath of battle and during camp life. The Civil War was not a stranger to unpleasant features including severely wounded soldiers, extreme surgical procedures, as well as acute infections and illnesses running rampant through the population. The medical practices and procedures of the time, although somewhat behind other parts of the world, were important to the success of the armies and development of modern medical practices.
During the Civil War, approximately 618,000 men were killed by battle and disease
(Faust, 1995). According to George Worthington Adams, approximately 300,000 Union men died. Confederate attacks are responsible for about one third of these deaths, with disease responsible for the remainder (Adams, 1980:3). The Union experienced a total of approximately
400,000 cases of injuries and wounds from battle, as well as 6,000,000 cases of illness between
1861 and 1865 (Adams, 1980:3). The Confederates suffered a similar amount of deaths in both battle and disease (Cunningham, 1986).
Medical Departments
The medical departments in both the Union and Confederate military were important to the success of their respective armies. The structure of both departments was similar. At the beginning of the war, each medical department had a surgeon general, with the equivalent
3 military rank of Colonel before 1861 and the rank of Brigadier General during and after 1862.
The Surgeon General was in charge of ordering supplies and medical tools for the surgeons, organizing medical personnel, and overseeing the entire military medical department.
Additionally, each medical department consisted of four surgeons, holding the rank of Major, and six assistant surgeons, with the rank of Captain or First Lieutenant. The surgeon general was paid $250 per month for his duties. A surgeon was paid $162 per month for running the battlefield hospital, and performing surgeries. The assistant surgeon received $110 per month for attending to the wounded on the battlefield, as well as other duties assigned by the surgeon.
The Confederate medical regulations for each regiment were quite similar to the regulations of the Union medical department. In writing the regulations at the Provisional
Congress, the Confederates neglected to account for the medical officers for each regiment.
Even though the regimental doctors were not included in the regulations, many regiments organized for regimental doctors to be present. The use of regimental doctors was not unusual for the Confederacy, as it was traditional practice in the U.S. Army (Freemon, 1998; Bollet,
2002).
The Confederacy employed two surgeon generals during the war. The first was David C.
DeLeon, who served for approximately three months. He was replaced by Samuel Preston
Moore, who would hold the position for the rest of the war.
The Union Medical Department was headed by four different surgeon generals during the four years of war. Surgeon General Lawson, known for his frugality with the medical department, died in office during 1861. Carrying on some of the same parsimony, Surgeon
General Finley was appointed to replace Lawson. Due to the fact that this war required more medical attention than was being provided, Finley was removed from office in 1862 in the hopes
4 of remedying the situation. Alexander Hammond took his place, and is responsible for many of the revolutions in sanitation and hygiene during the Civil War (Adams, 1980). Hammond’s revolutionary ideas were not always accepted, specifically due to the clashing of views between him and Secretary of War Edwin Stanton. Therefore, in 1864 Hammond was removed from office and stripped of his title. He was replaced by Surgeon General Joseph Barnes.
Hammond’s good character was later restored and, as a result, the honorable rank of brigadier general was bestowed upon him (Bollet, 2002; Brooks, 1966).
The medical standards in the United States were dreadful at the beginning of the Civil
War. Groups of concerned civilians determined that the United States needed a Sanitary
Commission similar to the one used in Britain during the Crimean War. The civilians were not in search of funding from the government for this endeavor; instead, they wanted the power to investigate the general conditions in which the soldiers lived including status of the camps, diet and clothing, hospital conditions, and overall sanitary conditions of the war. On June 9, 1861, the order to create the sanitary commission, granting the requested investigative ability to the commission, was signed, although there was some hesitancy, by Secretary of War Simon
Cameron. On June 13, 1861 it was signed into law by President Abraham Lincoln. The office of executive secretary of the sanitary commission was given to Frederick Law Olmstead. The sanitary commission, funded by civilians, gave food and medical equipment to the armies, as well as revolutionized regulations and camp life among the soldiers (Adams, 1980).
Doctors
During the Civil War, all doctors in the service of the military became surgeons. In the beginning of the war, the United States had regular army surgeons, who were in the service of
5 the army before the war and were used for staff duty; surgeons of state troops, who were commissioned by state governors and contract surgeons, received the same pay as a First
Lieutenant, but were not members of the army. Written and practical examinations were given to the regular army surgeons by the Army Medical Corps to determine the ability of the doctor and the appropriate level of appointment within the army. The rank and level of appointments picked up drastically during the war. Each state appointed the state troop surgeon and assistant surgeon to their regiments in different ways. Some states were very lenient with their examinations and appointments, whereas other states created examinations that were so difficult that very few surgeons passed. Overall, the surgeons appointed were considered adequate by the sanitary commission (Adams, 1980).
Another type of surgeon working during the war was the reserve surgeon or civilian volunteer surgeon. These individuals were often seen as opportunity seekers, looking to gain experience by testing surgeries on the soldiers and inspecting wounds. At Antietam, civilian surgeons were seen practicing their surgery techniques on the wounded, as well as leaving work undone, which they felt would be difficult or time consuming. These civilian volunteer surgeons were also known to remove a bandage, inspect the wound, and not rebind the individual (Adams,
1980; Brooks, 1966). Overall, the civilian surgeons were not well trusted by the army surgeons, because of their experimental techniques and lack of fortitude. By the end of April, 1865, more than 12,000 surgeons had served in the U.S. Army in a medical capacity (Adams, 1980). The
Confederates, on the other hand, only had approximately 3,000 surgeons who served during the entire duration of the war. These surgeons also went through rigorous board testing, in order to receive their appointments (Cunningham, 1986).
6 To become a doctor during the 19th century, individuals had to attend one of the few medical schools established in the United States or a medical school in Europe. Most medical schools were in the north, although during the antebellum period several medical schools were established in southern states as part of the movement toward southern nationalism
(Cunningham, 1986). Most medical school programs required two years of academic work consisting of repetitive lectures during the first and second year. This lecture series was to be followed by an internship with an established doctor. Since dissection was illegal in most states, lab and clinical lessons were not given at the schools. Also, many medical schools were not well equipped with available tools of the time. For example, Harvard medical school did not have stethoscopes until 1868, even though they were invented in the 1830s. The lack of proper tools was also evident in the war itself. During the war, many medical discoveries were taking place in Europe, but due to lag of information travel, the doctors receiving their training before and during the war did not learn of this information while in school (Adams, 1980). The training methods used in both U.S. and Confederate medical school were not superior, but they were better than some doctors of the time were receiving. The poor training could be illustrated by the fact that, during the mid 19th century, some medical schools became diploma mills, giving diplomas to some men after just weeks of training (Brooks, 1966). This overpopulation of under-qualified physicians created a problem with consistency and reliability of care.
Disease and Illness
The surgeons of the various regiments were responsible for taking care of both illness and injuries attributable to the war. Disease was the most prevalent cause of death during the Civil
War. The average soldier in the Union army fell sick approximately twice a year. There were
7 approximately 2,435 cases of illness for every 1,000 soldiers and the death rate from illness was approximately 53 for every 1,000 individuals. A Union soldier was five times more likely to die of disease than was a civilian during the same period (Adams, 1980). This prevalence, of course, varied from region and regiment. The three most deadly diseases of the time were called “the summer diseases.” These included malaria, dysentery, and typhoid. Yellow fever, meningitis, scurvy, measles, and small pox were also present during the war, but not to the extent of the
“summer diseases” (Freemon, 2001).
Diarrhea-dysentery occurred in approximately 711 individuals in every 1,000 soldiers
(71.1%). This disease was often blamed on poor, greasy diets and filthy living conditions, although it could have been an indicator of other diseases at work in the individual. Many doctors wanted to change the diet of these individuals to a more fresh variety of foods, unfortunately a fresh diet was not possible due to the constant movement of the armies and the lack of cultivation during the war (Adams, 1980). Today we know that the diarrhea can be caused by infectious organisms such as Entamoeba, salmonella, E. coli, and other easily spread organisms (Freemon, 2001). The treatment for this ailment consisted of either opium or laxatives being given to the patient (Adams, 1980). Many soldiers suffered from severe dehydration as a result of the diarrhea. This dehydration was exacerbated by the salivation produced by calomel, a medicine being given to stop the diarrhea (Freemon, 2001).
Typhoid fever, which presents itself as diarrhea, fever and pulmonary distress, was quite common during the Civil War. Mild forms of the disease were not always identified among the soldiers (Freemon, 2001). In order to treat this disease, the soldiers were given small doses of turpentine to heal the ulcers in the intestines; cold compresses were applied to alleviate the fever, as well as the spraying of water on the body to cool the internal body temperature. Sometimes
8 doctors thought typhoid fever was a masked version of malaria; so their treatment regime included giving quinine and/or doses of whiskey to the patient, as well as bleeding the individual to release the bad humors (Adams, 1980).
Malaria, which had approximately 522 instances per 1,000 in the Union army, was one of the most prevalent diseases during the war. This ailment is carried from one person to another through mosquitoes, which had a high prevalence in the South during the summer months
(Freemon, 2001). The treatment for this disease was mainly quinine, although some mercurial medicines were given, along with opium for pain (Adams, 1980).
Surgery
Illness and infection also resulted from wounds and the surgical procedures intended to heal those wounds. The wounds of the war were caused by three mechanisms: bullets (94%), artillery and grenades (5.5%), and bayonets or swords (.4%) (Figure 2.1). Of these wounds, 71% were sustained to the appendicular portion of the soldiers (arms and legs), while only eighteen percent were received to the axial portion of the body (head, torso and pelvis) (Adams, 1980).
Three different types of projectiles have been determined to be the main cause of wounds. These are the Minie ball or conoidal ball, the round ball, and shell fragments (Adams, 1980). The
Minie ball, a 0.58 caliber shot, traveled at approximately 950 feet per second and was responsible for the shattering and mangling of the bones of the appendages (Adams, 1980;
Bollet, 2002; Brook, 1966). These wounds were called compound comminuted fractures, due to the ruptured skin and multiple breaks in the bone (Bollet, 2002). All ammunition at this time could carry dirt and clothing with the shell. The additional debris, along with the extreme lacerations caused by this slow and robust ammunition, ultimately led to the infection of the
9 wound. Today, bullets are steel jacketed, allowing for a cleaner entrance into the body, as well as an extremely hot temperature from traveling at such high velocities. The high speed sterilizes the bullet before it enters the body, partially reducing the initial risk of infection. The difference in the bullets of today partly accounts for the reduction in bullet wound infection in modern warfare (Adams, 1980).
Figure 2.1: Wounding Mechanisms of the Civil War. Firearm ammunition including Minie Ball and Musket Ball, as well as, Bayonet to affix to musket or rifle. Artillery ammunition and sword excluded from image.
Many surgeons felt it necessary to probe and fish out the bullet and bone fragments from the wounded soldier. Probing was most easily done using an ungloved finger, which had, prior to the insertion into the wound, poked and prodded many wounds of other soldiers. The introduction of bacteria and aggravation of the wound was very high because of these practices.
Many men, who did not require surgical procedures, were bandaged with lint packed in their wounds. Lint was much like cotton balls used in today’s medical practices. The material was scraped from clean cloth, but was not disinfected.
The standard practice was to keep the bandages damp or have a constant drip of water on them, in order to keep the wound fresh (Adams, 1980). This constant drip of water was referred to as the cold water technique. Some surgeons did not agree with the cold water technique and
10 advocated for dry lint and bandages instead (Brooks, 1966). Today, applying water to bandages is frowned upon, because it creates an environment in which bacteria, such as Staphylococcus, can flourish. At the time, an infected wound producing pus was thought to be on the proper course to healing. The doctors believed the pus was the body’s way of purging the dead and sick portions of the wound and bone. It was not discovered until later that the pus was caused by bacterial infection.
Overall, cleanliness was very difficult to achieve during the war. Surgical tools, hands, clothes, and sponges were cleaned, only by rinsing them in a tub of bloody water or being placed under running water (Adams, 1980). Surgeon W.W. Keen demonstrated the unclean nature of the battlefield:
“We operated in old blood-stained and often pus-stained coats, the veterans of a hundred fights. We operated with clean hands in the social sense, but they were undisinfected hands…We used undisinfected instruments from undisinfected plush-lined cases, and still worse used marine sponges which had been used in prior pus cases and had been only washed in tap water. If a sponge or an instrument fell on the floor it was washed and squeezed in basin of tap water and used as if it were clean,” (Adams, 1980).
Surgery was a very frightening experience for the badly wounded soldiers. Many did not trust the medical practitioners, as stories of surgeons practicing new techniques and the large amount of dead resulting from the operations had preceded them. Men were also fearful because of the large amount of amputated arms, legs and sometimes even entire corpses piled next to the operating table.
Surgeons were aware of pain management and anesthesia during the war. The doctors used such medicines on a regular basis, even though it appeared to the soldiers that the doctors were quite cruel and harmful. The two main anesthesia used during the war were chloroform and ether, along with other variations of the two mixed together (Adams, 1980). Chloroform tended to be the more widely used of the two, due to its non-flammability. Today, chloroform is
11 rarely, if ever, used in medical practices (Brooks, 1966). Approximately 80,000 anesthetic doses were given during the Civil War. In general, there was a very low mortality rate from anesthesia, which may be due to the fact that most surgeries were performed outside, where the chloroform was mixing with the fresh air, therefore losing some of its strength. Some doctors felt that anesthesia would be harmful to those experiencing shock, and that same shock a patient was experiencing could carry the individual through the surgery (Adams, 1980).
Pain medicine was also extremely important to the medical scene of the Civil War. The main form of analgesic was opium, which was administered in a pill form. Most soldiers were automatically given opiates, regardless of the severity of their wound. Hypodermic needles were not introduced until late in the war, so many pain medicines, such as morphine, were instead dusted into the open wounds of the soldiers. Alcohol was also used to control pain, although this practice is considered quite erroneous by today’s medical standards (Adams, 1980).
Amputation
Amputation is the most well known surgery performed during the Civil War. In the
Union alone, approximately 30,000 amputations were recorded, which do not include surgeries performed in hospitals and after the war. Confederates are estimated to have performed approximately the same amount of amputations. At the time, amputations usually took from about two to six minutes to perform (Bollet, 2002). This form of treatment has received the most criticisms of all medical practices of the War. There are many reasons amputation was the best route for the soldiers at large. Most bullet wounds received would eventually become infected and possibly lead to death. Many soldiers were so worn down from the hardships of war, they could not stand resection or invasive surgery. Also, many surgeons worried about the
12 environment and manner in which the wounded would be transported and healing, therefore, surgeons felt it would be better to remove the damaged area entirely (Adams, 1980). Some surgeons performed resections or excisions, instead of amputation, in hopes that the area would repair the defect during the healing process. Resections or excisions usually took away most of the bony support of the individual, had a longer healing time than amputation, and would make life more difficult than using prostheses (Bollet, 2002).
There were two time periods during which an amputation could be performed. The first was called a primary amputation, which occurred within 24 hours of when the wound was sustained. Usually, the procedure was performed before infection had appeared. The second type was called a secondary amputation. This surgery occurred at least 24 hours after the wound had been received (Adams, 1980; Brooks, 1966). Overall, primary amputations had a higher rate of success and survival than the secondary form. Some of the surgical tools used during the
Civil War are similar to various tools used today, others were quite alarming, but were used for their quickness of cutting through the bone. These tools included very long and slender knives and early chain saws (Bollet, 2002).
Two styles of amputation were conducted during the Civil War. The first was a circular amputation in which the limb was cut directly through, leaving an open wound at the end of the limb. The flap method, devised by William Cheselden in the 18th century, was a procedure in which the amputation was left with a flap of skin to cover the wound. This method took longer to perform than the quick sawing through, but tended to lead to more satisfactory healing and a better “stump.” During the war, there were many disagreements about the most appropriate method to use. The advocates of each practice accused the opposing side of great hemorrhages, more infection and skin sloughing. Overall, the flap method was a more delicate procedure due
13 to the necessary arterial ligatures and extra time needed to perform the operation. This type of
procedure was not always possible due to the extreme amount of medical attention needed,
especially during and directly after a conflict (Bollet, 2002; Adams, 1980). According to the
Medical and Surgical History of the War of the Rebellion:
“the circular operation required less time and care in dressing, was easily handled, seldom sloughed, that its discharges were less and that it was less frequently followed by hemorrhage than the flap operation, while the latter mode would not stand transportation unless carefully supported, and was considered altogether too nice an operation for the flurry of the battlefield. As far as stumps are concerned, handsome round stumps were achieved by either method,” (MSHWR, vol. 3).
Social Ramifications of Amputation
During the Civil War, there was a high level of social discrimination toward
individuals with disfigurements. Marital engagements were even ended due to the news
of the amputation of a soldier’s limb. In an effort to overcome some of the stigma
associated with this condition, development of prosthetics accelerated during and after
the war. The federal government eventually spent part of its budget on prostheses for the
soldiers who had suffered an amputation. After the war, a large part of the budget in
former confederate states was spent on artificial limbs. Even high ranking military
commanders suffered from amputation, such as Confederate generals John Bell Hood and
Richard Stoddert Ewell. These generals both used prostheses and went back into the
field with amputated limbs (Bollet, 2002).
14 Chapter 3: Bone Biology
In order to understand the processes leading to the infection of human bone that result from trauma produced by military action, a comprehension of the biology of the human skeleton is essential. The skeleton provides many functions for the human body. These functions include the structure and movement of the body, storage of important nutrients, such as calcium and phosphates, protection of organs, as well as hematopoiesis, or blood formation (Adler, 2000). To perform these functions properly, the human skeleton is constantly forming and changing through the processes of ossification, modeling, and remodeling.
Bone Maintenance Cells and Composition
All skeletal elements are made up of osteoid (bone matrix), which is a gel-like mixture of water, collagen, non-collagenous proteins, and proteoglycan. This mixture is stiffened by inorganic mineral components such as hydroxyapatite. These components make the skeleton extremely strong, yet lightweight and flexible (Tersigni, 2005; White and Folkens, 2005).
There are four types of cells responsible for the maintenance of skeletal tissue: osteoprogenitor cells (and future osteoblasts), osteoclasts, osteocytes, and bone lining cells
(Figure 3.1). Osteoprogenitor cells are housed in the bone marrow of young individuals, who are experiencing growth. There is also some speculation that these cells are present in the periosteum and endosteum of the bone (Belezikian, 1996; Ortner, 2003; Tersigni, 2005).
Osteoprogenitor cells develop into pre-osteoblasts and eventually mature osteoblasts. The mature osteoblast is responsible for the deposition of osteoid in the processes of ossification, modeling, and remodeling. The life span for the osteoblast is approximately six months.
Osteoblasts, then, become either osteocytes or bone lining cells. A bone lining cell develops
15 when bone synthesis stops. At this point, the cell flattens and encloses the outer surface of the bone. These cells are less complex than other bone maintenance cells, but provide protection from the resorption process (Ortner, 2003).
The osteocyte, which also develops from the osteoblast, is the true bone maintenance cell.
These cells are osteoblasts that have been trapped in bone matrix secreted by other surrounding osteoblasts. Between 10-15% of osteoblasts eventually develop into osteocytes. Osteocytes dwell in almond-shaped openings in the bone matrix, which are called lacunae. The jobs of the osteocyte include the aiding in secondary mineralization of the bone, a small amount of resorption and deposition of matrix, as well as communication from cell to cell and on a larger scale from periosteum to endosteum. The communication takes place through an ion charged liquid being forced through the canaliculi (finger-like projections extending from the osteocyte).
The fluid produces chemical and hormonal signals, which are transmitted to the adjacent canaliculus of another osteocyte through ion transfers at gap junctions (small spaces between each canaliculus and the next) (Ortner, 2003; Tersigni, 2005).
The fourth type of bone maintenance cell is the osteoclast. These are destructive cells, which are responsible for the breakdown and resorption of the bone. These cells are significantly different than the previous types of bone maintenance cells because of their large size, unusual shape, multiple nuclei, and derivation from multiple hematopoietic stem cells (as opposed to mesenchymal stem cells, which derive osteoprogenitor cells). During the process of resorption, the osteoclast attaches itself to the bone, which in turn stimulates it to produce a ruffled border at the adjoining portions of cell and bone. This ruffled aspect allows for more surface area from which to secrete the acidic fluid that breaks down the bone matrix. The areas of the bone that have been resorbed serve as housing for the osteoclast and are called Howship’s lacunae
16 (Bilezikian et al, 1996; Ortner, 2003; Tersigni, 2005). Figure 3.1 depicts graphic representations of these four cell types.
Figure 3.1: Bone Maintenance Cells.
Anatomy of Bone
There are four categories of bone in the body: long bones, short bones, flat bones, and irregular bones. Long bones and short bones are generally tubular in shape and flare at the ends; these would include bones such as the femur, humerus, clavicle and metatarsals (Figure 3.2).
Flat bones are usually tabular in shape and consist of bones such as ribs and the bones of the cranial vault (Figure 3.3). Irregular bones are those bones that are not easily classified into one of the previous categories. Some examples of this type are the carpals and tarsals or the sphenoid (Figure 3.4). All bones are covered by a protective osteogenic tissue called a periosteum, while the inner portion of the bone and inner surfaces of bone microstructures are covered by a tissue called the endosteum (Tersigni, 2005; White and Folkens, 2005).
17 Figure 3.2: Digital Image of Long and Short Bones(Clavicle, Radius, Ulna, Humerus, Tibia and Femur from normal specimen 2000.0016.01 at the National Museum of Health and Medicine).
Figure 3.3 Digital Image of Flat Bones (Cranium and Ribs from normal specimen 2000.0016.01 at the National Museum of Health and Medicine).
Figure 3.4: Digital Image of Irregular Bones (Tarsals, Carpals and Sacrum from normal specimen # 2000.0016.01 at the National Museum of Health and Medicine).
18 Skeletal Development
The bones of the human body develop through two different types of ossification:
intramembranous ossification and endochondral ossification. The process of intramembranous
ossification is responsible for the formation of the flat bones of the body such as the cranial and
facial bones, as well as increasing the diameter and thickness of the tubular bones.
Endochondral ossification forms the long and tubular shaped bones, such as the humerus, femur
and tibia (Ortner, 2003; Tersigni, 2005).
During intramembranous ossification, the newly differentiated osteoblasts lay down
osteoid (bone matrix) in cartilaginous membranes of the flat bones, at specific focuses or centers
of ossification. Endochondral ossification begins through appositional development. During appositional development, bone matrix is laid down on top of existing tissue that acts as a mold for the bone matrix to obtain the necessary shape. In the case of endochondral ossification, it is the cartilaginous framework of each bone that the bone matrix is laid upon. The oldest cells, at the midpoint of each structure, experience hypertrophy (an increase in cell size), which stimulates the mesenchymal cells to become osteoprogenitor cells. Once the osteoprogenitor cells out number the chondroblasts at this site, the perichondrium (the outer tissue which surrounds cartilage) becomes the periosteum. At this point, the periosteum is able to stimulate osteoblasts to form a ring of bone surrounding the middle portion of cartilage, which will eventually become the diaphysis or shaft of the bone. Osteoclasts are also activated at this point, in order to create tunnels for capillaries, which are necessary for the transport of osteoprogenitor cells to the center of this bony ring. When osteoprogenitor cells reach the central area, the primary ossification center is formed. At this time, blood vessels are also infiltrating the end portions of the bone at the secondary centers of ossification. This area will eventually form the
19 epiphyses. The epiphyses are separated from the diaphysis by a cartilaginous epiphyseal plate
(physis or growth plate). A growing long bone consists of a diaphysis (shaft), with broad ends called metaphyses, along with a physis and epiphysis at each end (See Figure 3.5) (Ortner, 2003;
Tersigni, 2005; White and Folkens, 2005).
Figure 3.5: The Process of Endochondral Ossification.
Modeling and Remodeling
During bone growth, a process called modeling is necessary to achieve the appropriate size and shape of each bone. This process contains both deposition of bone matrix by osteoblasts and resorption of bone matrix by osteoclasts at the appropriate sites on each bone. At this point, the diaphysis is growing longitudinally. Osteoclasts are removing bone on the periosteal surface where the diaphysis and metaphysis meet, while osteoblasts are laying down bone matrix on the endosteal surface of the articular aspect of the metaphyses (Figure 3.6). Flat bones experience a
20 similar form of modeling, but osteoblasts are instead laying down bone matrix on the periosteal surface, while osteoclasts are removing bone from the endosteal surface (Ortner, 2003; Tersigni.
2005).
Figure 3.6: Directional growth during endochondral ossification.
After bone development and epiphyseal fusion, the bone is still continuously changing through a process called remodeling. This process does not change the appearance of the bone, but instead maintains the structure and integrity of the already existing bone. Remodeling occurs on a continuous basis to repair micro-fractures caused by daily use of the skeleton. The process of remodeling is also stimulated in instances of trauma, where bone must be repaired or rebuilt because of macroscopic damage to the bone. During remodeling, there are episodic resorptions and depositions of bone matrix throughout the skeletal system. (Ortner, 2003; Tersigni, 2005,
White and Folkens, 2005).
Depending on the age of an individual, each of the categories of bone can have one of two types of bone structure. The first type is woven bone, which is sometimes termed immature
21 or fiber bone. This type of bone is associated with rapid growth as is seen in children and healing, therefore, it is only observed in individuals up to the age of five or at sites of trauma.
The structure of this bone is unorganized and weak in comparison to the second type of bone
(Bilezikian, 1996; Ortner, 2003; Tersigni, 2005) (Figure 3.7).
Mature or lamellar bone is the subsequent type of bone and is present in adolescents and adults (Figure 3.7). It is highly organized in structure and strong and rigid in comparison to woven bone. Mature bone can be separated into two different forms: trabecular (or spongy bone/ cancellous bone) and cortical (or compact bone). Trabecular bone is a porous type of bone that has a spongy-like appearance due to the presence of connective spicules, also known as trabeculae. This type of bone is found in flat bones and the epiphyses of long bones (Figure 3.8).
Cortical bone has a dense structure. This type of bone forms the shafts of long bones, as well as the layer of bone covering all trabecular bone. (Ortner, 2003; Tersigni, 2005) (Figure 3.8).
Within the compact bone, there are many small structural units that allow each aspect of the bone to have constant contact and communication with every other portion. These units include:
Haversian Systems (Osteons), Haversian Canals, and Volkmann’s Canals. Haversian Systems, also known as osteons, are circular structures consisting of concentric rings of compact bone containing lacunae (which house the osteocytes) surrounding a Haversian Canal (Figure 3.9).
Haversian Canals are channels, running vertically in the bone that forms around blood vessels and nerves for their easy passage throughout the bone. The blood vessels are an integral part of nutrient transport and communication with in the skeletal system. The systems which horizontally link Haversian Canals are called Volkmann’s Canals. These pathways also allow nerve communication to occur between the endosteum and periosteum. Communication between the osteogenic tissues is important in the process of bone trauma and fracture repair because
22 osteoblasts and osteoclasts reside on the surface of the periosteum and need to be activated in order to repair the damaged area (Ortner, 2003; Tersigni, 2005; White and Folkens, 2005).
Understanding the normal processes of skeletal development and remodeling is paramount when determining the damage caused by trauma or disease. These changes can be easily confused for pathological disorders, but can also be important physical indicators of the course of a disease, such as osteomyelitis.
Figure 3.7: Woven and Lamellar Bone.
23 Figure 3.8: Digital Image of Compact and Trabecular Bone (Femur from normal specimen 2000.0016.01; Femur Midsection from specimen 1000990 at the National Museum of Health and Medicine).
Figure 3.9: Haversian System and Volkmann’s Canal.
24 Chapter 4: Osteomyelitis
During the Civil War, there was a high prevalence of skeletal trauma among combat soldiers. This increased incidence of trauma brought about many pathological conditions of the skeleton. One of the most visible of these conditions was osteomyelitis. Osteomyelitis is a pus- producing infection (sometimes called a suppurative, pyogenic or purulent infection) of the inner cavity of the bone shaft, also known as the medullary cavity. This infection specifically affects the endosteal or inside surface of the bone and is caused by the presence of abnormal pus- producing bacteria, most often Staphylococcus aureus (Adler, 2000; Aufderheide &Martin,
1998; Ortner, 2003; Rockwood & Green, 1984). Although this infection occurs in the medullary cavity and endosteal surfaces of the bone, there can also be external signs of infection. This type of infection can occur in any bone of the skeleton and is not restricted to a single subset of the human population.
Hematogenous Osteomyelitis
The first category of osteomyelitis, classified by the route of infection, is hematogenous.
Hematogenous Osteomyelitis can be described as an infection incurred from a blood-borne pathogen traveling from a distant infected area in the body (Ortner, 2003). Generally, the hematogenous type infects children in the metaphyseal aspect of their long bones, because of the high growth rate and large blood supply to the region. The ages most commonly infected in children or sub adults are between two and sixteen years old. However, adults can also be affected by this type of osteomyelitis both in the metaphysis and diaphysis of the long bones, as well as in the irregular bones such as vertebrae and tarsals (Adler, 2000; Aufderheide
&Rodriguez-Martin, 1998; Ortner, 2003). This type of infection is also frequent in those
25 individuals that have compromised immunity and chronic illness, as well as malnutrition and
immuno-deficiency diseases (Macnicol and Watts, 2005). The most commonly implicated
bones, from greatest to least involvement, are the femur, tibia, humerus, and radius (Aufderheide
& Rodriguez-Martin, 1998). Among affected adolescents, there is a 3:1 ratio of males to females
in the incidence rate of osteomyelitis. This skewed sex ratio is not present in infant groups and is significantly reduced in adult groups (Ortner, 2003).
The anatomy of sub-adult long bones is important in the development and spread of the infection. During the age range of most common infection, between two and sixteen years of age, the shaft and epiphysis of the long bones are separated by a growth plate. This growth plate not only separates the shaft of bone from the epiphysis of the bone, but also separates the vascular supply of the metaphysis and epiphysis from one another (Figure 4.1). Throughout sub- adult growth, there is a large blood supply to the metaphysis, which may allow for a greater influx of hematogenic bacteria to the metaphyseal region. The growth plate acts as a protective barrier between the infection and the epiphysis of the long bone and shields the joint of the child from infection. For these reasons, children usually experience a single focus of osteomyelitis, rather than osteomyelitis spreading across joints and to adjacent bones. As the child grows and the epiphyses fuse, the two portions begin to share veins and arteries, thus blood supply. This union explains the increase in joint and adjacent bone infections in older individuals (Figure 4.2)
(Aufderheide & Rodriguez-Martin, 1998; Macnicol and Watts, 2005; Rockwood and Green,
1975).
26 Figure 4.1: Vascular Anatomy of Sub-Adult and Adult Long Bones.
Clinical Development of Hematogenous Osteomyelitis
The development of osteomyelitis within the bone begins with the introduction of foreign bacteria to the body. The initial area of infection can include skin abrasions, dental procedures, catheterization and other surgical procedures that may produce a soft tissue wound (Macnicol and Watts, 2005). The most common bacterium found to cause osteomyelitis is Staphylococcus aureus, which is responsible for 80% of cases. Additionally, Streptococcus B, Pseudomonas,
Salmonella, Mycobacterium tuberculosis, Spirochaetes, as well as various fungi, viruses, and helminths can account for the other 20% of the cases (Bohndorf, 2004).
Regardless of the strain, the infective bacteria in the blood enters the bone through a nutrient artery and eventually seeds in a sinusoidal vein. The infection can then quickly spread through the bone by way of the blood vessels that reside in the Haversian and Volkmann’s canals, usually in a lateral direction or in the path of least resistance. An increase in intraosseous
27 pressure, created by an exudation of fluid and an influx of leukocytes (white blood cells), helps move the infection within the open pathways. Within 48-72 hours after the initial contamination, the infection reaches the metaphyseal cortex and proceeds to lift the periosteum away from the bone. In adults, the periosteum cannot be lifted, as it is firmly attached to the cortical bone; instead the pus produced by the infectious bacteria bursts directly through the periosteum. With this large amount of pus being formed, as well as subperiosteal abscesses, the fluid will eventually come through the periosteum and form a draining sinus to the skin. The large amount of pressure created by the pus in the medullary cavity and subperiosteal space restricts the blood supply to the bone. This restriction of blood, along with the bacteria attacking the osteocytes, begins the process of bone necrosis or bone death. The portion of dead bone, which remains, is classified as the sequestrum (Figure 4.2).
As the living bone attempts to battle the infection, osteoclasts are activated to separate the living bone from the dead bone. The presence of osteoclasts stimulates the periosteum to start the process of bone formation. Eventually the new bone envelops the sequestrum. This honeycomb like structure of woven bone is called the involucrum (Figure 4.2). The process of involucrum development can occur within ten to fourteen days of the initial infection. The space between the involucrum and sequestrum is filled with pus, fluid, and sometimes pieces of dead bone, which will eventually be released by the forming of fistulas and/or cloacae (large and small openings in the involucrum) (Figure 4.3). Over time, pus and fragments of the sequestrum are discharged through the cloacae or fistula to a sinus and out of the body (Adler, 2000;
Aufderheide & Rodriguez-Martin, 1998; Macnicol and Watts, 2005; Rockwood and Green,
1975).
28 Figure 4.2: Digital Image of an Involucrum and Sequestrum (Specimen # 1002267 at the National Museum of Health and Medicine).
Figure 4.3: Digital image of Cloacae and a Fistula. (Specimen #’s 1002667 and 1002669 at the National Museum of Health and Medicine).
Clinically, hematogenous osteomyelitis is identified by the patient experiencing chills,
fever and malaise, pain and local swelling, as well as positive blood cultures and positive
radiographic images of the diseased bone (Lew and Waldvogel, 2004). The treatment for the
infection depends upon the causative bacteria. In contemporary society, a specific antibiotic
29 treatment is prescribed and a surgical procedure is performed to drain the pus and fluid in order to release the pressure.
Exogenous Osteomyelitis
In contrast to hematogenous osteomyelitis, exogenous osteomyelitis, or post-traumatic osteomyelitis, is a bone infection incurred by direct introduction of bacteria into an area of the body that has sustained trauma. This type has also been called contiguous focus osteomyelitis, though the definition of contiguous suggests that the infection began in the joint or soft tissue surrounding the trauma, rather than in the bone itself. In order for this type of infection to occur, the trauma must breach the skin and mucus membranes, so that the bacteria can easily colonize the tissue underneath. Opportunities for easy colonization occur because severe trauma usually leaves clotted blood, and dead or damaged soft tissue, which are ideal breeding grounds for the infectious organism. The traumas that can induce this type of infection include open fractures, amputations, prosthetic implants and other injuries which expose the bone (Holtom et al., 1999;
Mader et al., 1999; Tsukayama, 1999).
Most traumas are contaminated by bacteria, but only a small amount of those injuries actually become infectious. The trauma cases that do become infectious usually receive the bacteria from a hospital setting. The most common pathogens contracted in hospitals are coagulase positive staphylococci and Gram negative bacilli. Staphylococcus aureus is particularly interested in binding with bone, because of its affinity for attaching with proteins, such as the collagen found in bone. Staphylococcus is also able to attach to metal, which increases the rate of osteomyelitis in individuals with prosthetic implants (Tsukayama, 1999). In
30 addition, individuals with hypotension, poor debridement of a fracture, malnutrition and a history of alcoholism or smoking tend to be more vulnerable to these bacteria (Mader et al., 1999).
The course of the infection occurring in exogenous osteomyelitis mimics the course seen in hematogenous osteomyelitis. Initially, the host has an inflammatory reaction to the infection.
Occasionally, the trauma incurred by the victim delays the inflammation, as well as impairs the function of polymorphonuclear leukocytes or the white blood cells released by the bone marrow.
The appearance of a foreign object, such as a bullet or implanted hardware, in the wound can also decrease the bodily response against the bacteria. After the acute inflammation, there is an increase in pressure due to the fluid and defense cells drawn to the area. The increased pressure causes necrosis of tissue and hematopoietic cells, as well as the breakdown of trabeculae within the bone. The progression of the infection from this point is exactly like that of hematogenous osteomyelitis described previously (Tsukayama, 1999).
In clinically identifying post-traumatic osteomyelitis, the patient may present localized bone tenderness, swelling and drainage around the trauma area, fever, and chills, among other signs of infection. Diagnosis of both exogenous and hematogenous osteomyelitis is also based upon the identification of the pathogen causing the infection. The pathogen is discovered through blood cultures from the diseased area. These blood cultures can only be taken between
24 to 48 hours after antibiotics have been stopped, so that the medication does not interfere with the results of the culture (Mader et al., 1999).
Chronic and Acute Infection
An acute infection is generally considered to have occurred abruptly and to last only a short duration, yet the condition itself is progressing rapidly. Chronic infection is considered to
31 be a condition that lasts a long time and only experience slight to no changes in the infection.
According to the U.S. Center for National Health Statistics, chronic conditions are those that last for three months or longer. For the purpose of the research at hand, the definition from the U.S.
Center for Nation Health Statistics will be the guideline used to determine the duration of the present infection (Shiel and Stöppler, 2008).
Historic Treatment of Osteomyelitis
Before Pasteur’s discovery of bacteria in 1869, osteomyelitis was only treated surgically.
Many surgeons attempted to remove the nonviable bone through excision of the bone, a drilling of the medullary cavity, and scraping of the bone until blood was drawn. The most commonly used and preferred surgical treatment for osteomyelitis was amputation (Holtom and Smith,
1999). During the Civil War, osteomyelitis was a common occurrence after trauma, especially following the surgical trauma of amputation. The rate of reamputation, as a treatment for contracted osteomyelitis, was quite high during and after the war.
Clinical Classification of Osteomyelitis
Many classification systems have been developed to describe the level of severity presented in osteomyelitic cases. Kelly et al. (1970) proposed a classification in which they divided osteomyelitis into four categories depending on the etiology of the infection. The issue with this approach is that one would need to have the full medical history of the individual in order to determine such a specific etiology.
Another classification system was developed by Weiland et al. (1984), which classified osteomyelitis into three categories determined by the amount of bone exposed and the area of the
32 bone that is infected. Not only does the Weiland et al. system use bone for classification, but also the variation in soft tissue surrounding the infection.
May et al. (1989) developed a classification system for the infection of the tibia and fibula. This system categorized the infection into five types, based upon the load-bearing capabilities of the bones, as well as the time and course of reconstruction and healing of the pertinent infection. The drawback of the May system is that it is intended strictly for use with fully fleshed, living individuals.
The most commonly used system for the classification of osteomyelitis is known as the
Cierny-Mader classification system. This system uses the physiological status of the patient, as well as the amount of involvement of the bone and treatments of the bone and soft tissue leading up to the point of analysis. Four types, or stages, were defined depending on the way in which the dead bone is treated (such as bone grafts and coverage), as well as concerns with the infection of the soft tissue of fully fleshed individuals (Cierny and Mader, 1984).
Although each of these systems is quite useful in the medical field, physical anthropologists may find these classification systems very difficult to use. As these classifications either require an extensive medical history of the specimen or a fully fleshed and living individual, their application is not plausible in most historic and prehistoric cases of skeletonized remains.
In physical anthropology, there are two main classification systems being utilized. The first system, presented in Standards for Data Collection from Human Skeletal Remains (Buikstra and Ubelaker, 1994), the observed pathological features of remains are divided into nine categories. The categories include: abnormal bone shape, abnormal bone size, bone loss, abnormal bone formation, fractures and dislocations, porotic hyperostosis/cribra orbitalia,
33 vertebral pathology, arthritis and miscellaneous conditions. This system is used to determine all
pathological disorders, instead of a specific osteomyelitic case. In order to record the features
seen in cases of osteomyelitis, an individual must determine the specific code for features, such
as involucrum, sequestrum or cloacae. Although this system is a great way to record observed
pathological features on the skeleton, it does prove a bit difficult unless you are very familiar
with the coding scheme. The method also does not allow you to infer information, such as
etiology or duration, about the osteomyelitic lesions.
The Backbone of History: Health and Nutrition in the Western Hemisphere (Steckel and
Rose. 2002) is a book containing data collected from the Global History of Health Project. The goal of the Global History of Health project is to measure and analyze trends in health among populations around the world, ranging from Paleolithic to early twentieth century individuals.
The category being used to describe osteomyelitis is the “infection/periosteal reaction” category.
In this system, the researchers examine the active and healed lesions on the skeleton. Mainly, the project is focused on tibia lesions, by rating them from 1 (no involvement) to 5 (most severe).
The Global History of Health project also includes a section for the remaining skeletal material, with a similar 1-5 rating system. Although this is an excellent system for establishing the presence of an infection, the system does not give detailed information about the infection.
The most useful and parsimonious way to classify osteomyelitis in skeletonized remains is through the Etiology of the infection (“Hematogenous” or “Exogenous”), Duration of the infection (“Chronic” or “Acute”; if the medical information is available), and Severity of hyperostosis (“Minor”, “Moderate”, and “Severe”). The method of classification proposed in this research employs these three categories and defines how to determine the Etiology,
Duration, and Severity based on a gross morphological assessment of the skeletal elements.
34 Chapter 5: Materials and Methods
This research was performed at the National Museum of Health and Medicine (NMHM), a branch of the Armed Forces Institute of Pathology, located on the Walter Reed Army Medical
Center Campus in Washington D.C. The NMHM was founded during the Civil War, by
Congressional orders, as the Army Medical Museum. This museum houses the AC2 skeletal collection that was used in this research. The AC2 skeletal collection is composed of approximately 2,000 specimens of pathological disorders present in soldiers during or as a result of the American Civil War. The collection began in 1862 in an effort, by Surgeon General A.
Hammond, to obtain information for the Medical and Surgical History of the War of the
Rebellion (Barnes et al., 1876). This information was published in a voluminous text recounting the effects of war and disease on the U.S. population and the anatomy of the human body. The specimens were collected from several sources: during surgical procedures, on the battlefield, from private collections, and even directly from graves. In essence, this text is considered the first epidemiological study undertaken in the United States (Barnes et al., 1876). Using a subset of specimens from this well-documented collection of historic skeletal remains, the researcher explored the possibility that occurrences of osteomyelitis can be placed in more specific descriptive categories based on macromorphology. If successful, this study will enable physical anthropologist to draw reliable conclusions about the origins of osteomyelitis in individuals.
Specimen Selection
Bones were selected for analysis based on the criterion that the specimen was an amputation stump or bone removed after amputation, through reamputation, or excision. Bones examined in this research include: humeri, radii, ulnas, femora, tibias, and fibulas.
35 Gross Visual Analysis
A total of 77 samples met the amputation criterion, and thus were selected for this
analysis. Each specimen was closely examined and the following information about each
specimen was recorded on an osteomyelitis recording form (Appendix A): amputation type
(diaphyseal or epiphyseal, primary or secondary, and circular or flap method), skeletal element,
side, infected area, aspect of infection, etiology, severity (of hyperostosis), presence (and
amount) or absence of cloacae, presence or absence of sequestrum, presence or absence of
involucrum, hospital location, and name of amputation surgeon.
In order to determine how to rate the more ambiguous sections, based on Etiology,
Duration, and Severity, the researcher developed the Wehri classification system of osteomyelitis for skeletonized remains (Appendix B).
Etiology: Two classifications were possible for etiology: “Exogenous” or
“Hematogenous.” A specimen was considered to exemplify “Exogenous” osteomyelitis if the
infection was present and well developed at the site of trauma in the bone (amputation in this
research). If the infection is a transfer from a post-traumatic infection in an adjacent bone, that
infection is also considered to be “Exogenous” osteomyelitis (Figure 5.1). “Hematogenous”
osteomyelitis is an infection that is present at any portion of bone but is not associated with
specific bone trauma. The infection must have traveled from a distant focus of infection from
another part of the body (e.g., infection in the mouth that transfers to a tibia) (Figures 5.2).
36 Figure 5.1: Digital image of a partial femur that is an example of the “Exogenous” Etiology category. Note the centralized infection, that is not associated with the trauma of amputation. (Specimen 1001373 from the National Museum of Health and Medicine).
Figure 5.2: Digital image of a partial femur that is an example of the “Hematogenous” Etiology category. Note the presence of infection in association with the trauma of amputation. (Specimen 1002750 from the National Museum of Health and Medicine).
Duration: “Acute” infections were those that lasted only up to three months. Infections
that lasted longer than three months were considered “Chronic”. Duration could only be
determined in instances where the full medical history of the specimen was present. The
Duration of an infection cannot be determined through the judgment call of a researcher.
Severity: Severity of each infection was determined by virtue of the degree of
hyperostosis present in each specimen. Every specimen had to meet at least three of the criterion
listed and described in Table 5.1.
37 Table 5.1: Levels of Severity of Hyperostosis in Osteomyelitis.
All morphological features present on the bone can be observed (for example, nutrient foramen, fossa, tuberosities, crests, etc.). The bone retains a recognizable shape. Minor There is a slight outward curve at the periosteal surface of infected area. The periosteal surface still retains the compact bone appearance. The Involucrum or sequestrum are not present. See Figure 5.3 for an example. Few distinguishable morphological features of the bone are present. The bone still retains some portion of recognizable bone shape or macromorphology (i.e., triangular form of the tibia, recognizable epiphysis, etc.) Moderate The bone has a noticeably larger circumferential width than a normal specimen, but has less than a 1x larger circumferential width. In some areas, smooth compact bone is replaced by appearance of woven bone, with characteristic ridge and furrow (or honeycomb) system, called the involucrum, on the periosteal surface at the site of infection, while some portions of this area continue to retain recognizable compact bone. See Figure 5.4 for an example The morphological features of bone are no longer discernable. The bone shape (macromorphology) is distorted/disfigured from the normal shape and appearance. Severe Bone has at least an approximately 1x larger circumferential width than a normal specimen. Involucrum (woven bone, complete with the characteristic ridge and furrow system) covers entire infected area. See Figure 5.5 for an example
Figure 5.3: Digital image of a partial tibia and fibula that exemplify the “Minor Hyperostosis” category. Note the retention of compact bone on the periosteal surface and slight medial outward curvature of the tibia and fibula. (Specimen 1000385 from the National Museum of Health and Medicine).
38 Figure 5.4: Digital image of a partial femur that is an example of the “Moderate Hyperostosis” category. Note the replacement of compact bone by woven bone with the characteristic ridge and furrow system, as well as retention of some areas with compact bone. (Specimen 1000757 from the National Museum of Health and Medicine).
Figure 5.5: Digital image of partial femur that is an example of the “Severe Hyperostosis” category. Note the indistinct morphological features, involucrum covering the entire infected area, with a circumference of at least 1x larger than an uninfected femoral specimen. (Specimen 1002750 from the National Museum of Health and Medicine).
Documentation
Each specimen was digitally photographed in each of four anatomical orientations
(anterior, posterior, proximal, and distal) to record its gross external structure. In addition, any interesting or unusual areas of infection were digitally imaged at a higher magnification. For comparative purposes, each image included a control specimen that was a “normal” (non- pathological) bone matching that of the specimen. All images included a metric scale, upon which a printed label containing the collection specimen number was placed.
39 Data Compilation
Information about each specimen was entered into the SPSS 16.0 Data Editor (Appendix
C). Data for each specimen were supplemented by the medical information for each individual
that was available in the Medical and Surgical History of the War of the Rebellion (Barnes et al.,
1876). This supplemental information included the name of the amputation surgeon, dates of injury, amputation type, and in many instances, treatment. Records such as these were used to determine duration of the infection.
Statistical Analysis
Once the data were compiled into SPSS, a series of statistical analyses were carried out.
Basic frequencies were determined for Etiology, Severity, and Duration. A chi-squared test for independence was performed to determine possible relationships between categories. The same statistical test was also performed to demonstrate the relationship between Severity and specific morphological occurrences (involucrum presence, sequestrum presence and cloacae presence).
Each set of chi-squared tests was carried out with all specimens, as well as with the undetermined specimens removed from the sample. The results and explanations of these statistical methods are presented in Chapter 6.
40 Chapter 6: Results and Discussion Results
Frequencies of “Minor,” “Moderate,” “Severe,” and “Undetermined” cases in Severity are presented in Figure 6.1. Of the 77 specimens being rated for Severity 14 were “Minor,” 18 were
“Moderate,” 29 were “Severe,” and 16 were considered “Undetermined”. Concerning Etiology
(Figure 6.2), 56 of the 77 specimens were determined to be “Exogenous,” five were determined to be “Hematogenous,” and 16 were considered “Undetermined.” When rating Duration (Figure
6.3), it was determined that four of the specimens were considered “Chronic,” 28 were considered “Acute,” and 45 were “Undetermined.”
A chi-squared test for independence was applied to the category of Severity (Sequestrum,
Involucrum and Cloacae presence) to evaluate whether there was an association between morphological features and Severity level. The first chi-squared test was performed with all 77 specimens (Table 6.1). A second chi-squared test excluded the four “undetermined” specimens to eliminate the possibility that these specimens may have skewed the test results (Table 6.2). A chi-squared test was also performed in order to demonstrate the independence of the categories of Etiology, Severity, and Duration (Table 6.1 and 6.2).
Figure 6.1: Frequency of Severity Figure 6.2: Frequency of Etiology.
41 Figure 6.3: Frequency of Duration.
Discussion
Severity and Sequestrum
The null hypothesis states that there is no relationship between Severity level and the presence of a sequestrum in a specimen. In the case where all specimens were tested, the chi-squared value was 13.436 (Table 6.1), hence, the null hypothesis can be rejected (p=.004) (Blalock 1972:569).
For the second chi-squared test, the null hypothesis could be rejected (chi-squared=5.332; p=.070) (Table 6.2) (Blalock, 1972:569). Rejection of the null hypothesis shows the large number of sequestrum only specimens in the sample size, because of the inability to categorize the variation in Severity without other morphological features of the long bones. By determining that the sequestrum only specimens are unable to be categorized, it can be said that this system is not useful on sequestrum only specimens.
Severity and Involucrum
When all specimens are included, a chi-squared value of 32.111 was obtained (Table
6.1). The null hypothesis, stating there was no relationship between Severity level and the presence of an involucrum, was rejected (p=.000) (Blalock, 1972:569) When the undetermined specimens were removed from the sample, again, the null hypothesis was rejected (chi-
42 squared=21.129; p=.000) (Table 6.2). Thus, the alternative hypothesis that there is a relationship between Severity level and the presence of the involucrum can be accepted in both instances.
Table 6.1: Chi-squared test results for all Specimens
Test Value Degrees of Freedom P-Value
Sequestrum x Severity 13.436 3 .004
Involucrum x Severity 32.111 3 .000
Cloacae x Severity 41.750 3 .000
Etiology x Severity 60.744 6 .000
Duration x Severity 9.849 6 .131
Etiology x Duration 9.798 4 .044
Table 6.2: Chi-squared test results with undetermined specimens removed.
Test Value Degrees of Freedom P-Value
Sequestrum x Severity 5.332 2 .070
Involucrum x Severity 21.129 2 .000
Cloacae x Severity 30.450 2 .000
Etiology x Severity 4.666 2 .097
Duration x Severity 1.446 2 .485
Etiology x Duration 4.714 1 .030
43 Severity and Cloacae
When either all specimens or only classifiable specimens are considered, the null
hypothesis that there was no relationship between variation in Severity level and the presence of cloacae can be rejected (p=.000) (Tables 6.1 and 6.2). Therefore, there is an association between variation in Severity level and the presence of cloacae.
Severity and Etiology
The null hypothesis being used to test all specimens was that there is no association between the variation of Severity and the category of Etiology, was rejected (chi-squared
=60.744; p=.000). When the undetermined specimens are removed, a contrary result is achieved
(chi-squared=4.666; p= .097) (Table 6.2). Thus the null hypothesis that there is not a relationship between the variation of Severity and Etiology could be accepted. The result
supports the concept that the undetermined specimens skew the overall outcome of the chi-
squared test and that it is only by chance that specific combinations occur.
Severity and Duration
The null hypothesis in this instance was that there is no association between the variation
of Severity and the variation of Duration. The value obtained for the chi-squared test for all
specimens was 9.849 (Table 6.1). When the undetermined specimens were removed, the
resulting chi-squared value was 1.446 (Table 6.2). In both instances, the null hypothesis could
be accepted (p=0131; p=.485) (Blalock, 1972:569). Therefore, it can be said that there is no
relationship between the categories of Severity and Duration.
Etiology and Duration
When considering all specimens, the null hypothesis tested stated that there is no
relationship between the two categories. The chi-squared value was 9.798 (p=.044) (Table 6.1),
44 therefore rejecting the null hypothesis. When the undetermined specimens were removed from
the sample, the chi-squared value was 4.714 (p=.030) (Table 6.2). Hence, the null hypothesis
could be accepted, demonstrating that there is no relationship between the categories of Etiology
and Duration.
Summary
Overall, the results of this research indicate that the system of classification introduced
above is a useful and statistically significant method for categorizing and studying osteomyelitis
in populations of skeletonized remains. A relationship was found to occur between the level of
Severity and the morphological features of sequestrum, involucrum and cloacae. However, there were no associations between the categories of Severity, Etiology and Duration. In the future, the results obtained in this research must be put to the test through comparative analyses of similar populations, as well as populations which are from different circumstances, in order to uphold the findings.
45 Chapter 7: Conclusion
Overall, the results of this research indicate that the descriptive system of classification detailed in this thesis is a useful tool for classifying and studying osteomyelitis in populations of infected human skeletonized remains. Although more research using this system is necessary, this preliminary study demonstrated the feasibility of closely examining and recording information about osteomyelitic remains when first encountered in the field or in laboratory settings.
As discussed in Chapter 1, this research addressed the issue of the lack of uniform scientific methods of descriptive analysis of pathological disorders in paleopathology. The approach taken by the researcher, to remedy this situation was to investigate and develop a system of classification for osteomyelitis. The system was developed through close research of previous methods being applied in both the fields of physical anthropology and contemporary medicine.
In order to properly conduct research on osteomyelitis, a population had to be chosen that would appropriately demonstrate the destructive nature of the disease, previous to the advent of the modern antibiotics. By choosing the amputees from the AC2 skeletal collection of Civil War
Soldiers at the National Museum of Health and Medicine (NMHM) in Washington D. C., there was a greater chance of finding the various types of osteomyelitis required to properly conduct the research. Contributing to the appropriateness of the collection were the medical practices during the civil war, the various types of traumatic events causing the amputation and the excellent medical records of each specimen in the collection.
A total of 77 specimens were examined for features including amputation type, skeletal element, area of infection, hyperostosis, cloacae, sequestrum, and involucrum. In looking at
46 these basic qualities of each infection, the specimens were easily placed into the categories
provided by the Wehri classification system of osteomyelitis. Along with written records of the
infections, each specimen was also digitally photographed alone and with a normal specimen for
comparison.
During analyzing, the Wehri classification system of osteomyelitis established in this
thesis has been proven to be more readily applicable to collections of skeletal remains than the
methods of classifying osteomyelitis detailed in Chapter 4. The system provides specific
morphological traits of long bones for each category of classification, thereby removing the
vague nature of other classification methods in paleopathology. The required morphological
features for each descriptive category were determined and tested through chi-squared tests of
independence. These tests showed associations between the morphological features present in
infected individuals and the category to which the infection was assigned. Specifically, a
significant relationship was found between the level of Severity and the presence of involucrum, sequestrum and cloacae in infected specimens. The research also determined a lack of association between the categories and thus demonstrated the need for separate categories through the use of the chi-squared test for independence.
In the end it is apparent that the Wehri classification system of osteomyelitis adds structure to paleopathology, as well as the ability to comparatively analyze populations with cases of osteomyelitis. Although this system was successful in the case of the Civil War soldier specimens, comparative studies are necessary to further assess the validity of the system for other types of populations. An area of future research would be to applying this system to populations that have benefitted from antibiotics. These populations would be contemporary remains, including individuals from post- Civil War conflicts, as well as other individuals who
47 have been exposed to the antibiotics used to cure osteomyelitis today. Similar research should be attempted on historic and prehistoric populations in order to further demonstrate the system’s usefulness for the field of paleopathology.
48 References Cited
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50 Appendix A: Osteomyelitis Recording Form
51 52 Appendix B: Wehri Classification System of Osteomyelitis for Skeletal Remains Etiology Exogenous or Hematogenous Exogenous: Infection will be present and highly developed at the site of trauma. If the infection is a transfer from a post-traumatic infection in an adjacent bone, that infection is considered to be exogenous osteomyelitis.
Hematogenous: Infection is present in any portion of a bone that is not associated with a specific bone trauma. The infection must have traveled from a distant focus of infection from another part of the body (e.g. infection in the mouth that transfers to a tibia).
Severity Minor, Moderate or Severe The severity of the infection is determined through the hyperostosis present in the specimen. Three categories are possible: Minor, Moderate or Severe Minor: All morphological features of the bone can be seen in the infected area (for example: nutrient foramen, fossa, tuberosities, crests etc). The bone retains a recognizable shape. Slight outward curve at periosteal surface of infected area. Periosteal surface still retains compact bone appearance. No presence of cloacae, involucrum or sequestrum Moderate: Few distinguishable morphological features of the bone are present in the infected area. The bone still retains some portion of recognizable bone shape or macromorphology (i.e. triangular form of the tibia, recognizable epiphysis etc.) Bone has a noticeably larger circumferential width than a normal specimen, but has less than a 1x larger circumferential width. In some areas, smooth compact bone is replaced by appearance of woven bone, with characteristic ridge and furrow (or honeycomb) system, called the involucrum, on the periosteal surface at the site of infection, while some portions of this area continue to retain recognizable compact bone. Severe: The morphological features of bone are no longer discernable in infected area. The bone shape (macromorphology) is distorted/disfigured from the normal shape and appearance. Bone has at least an approximately 1x larger circumferential width than a normal specimen. Involucrum(woven bone, complete with the characteristic ridge and furrow system) covers entire infected area. Duration* Chronic/Acute
Chronic: A chronic infection is one in which the disease has lasted over three months time.
Acute: An acute infection is one in which the disease has lasted up to three months time.
* This assessment is not meant to be a judgment call by the researcher, the assessment requires detailed medical records in order to determine the duration of the disease.
53 Appendix C: Specimen Data and Results Bones: 1=Femur, 2=Femur sequestrum, 3=Fibula, 4=Humerus, 5=Humerus sequestrum, 6= Radius, 7=Tibia, 8= Tibia sequestrum, 9=Ulna Etiology: H=Hematogenous, E=Exogenous, U=Undetermined Duration: A= Acute, C= Chronic, U= Undetermined Hyperostosis, Cloacae, Sequestrum and Involucrum: 0=Absent, 1=Present Severity: Mi= Minor, Mo= Moderate, S=Severe, U= Undetermined
AFIP # AMMPS# Bones Etiology Duration Hyperostosis Severity Cloacae Sequestrum Invou l cr um NA 3318 3 E C 0 Mi 0 0 0 384646 152 4 U U 0 Mi 0 0 0 384943 2047 1 H U 1 Mi 0 0 0 385118 5514 1 H A 1 Mi 0 1 1 1000385 3773 3 E U 1 Mi 0 0 0 1000385 3773 7 E U 1 Mi 0 1 0 1000765 3573 1 H U 1 Mi 0 0 0 1000910 267 4 E C 1 Mi 0 0 0 1001582 3518 3 E U 1 Mi 0 0 0 1002417 1175 4 E U 1 Mi 0 0 0 1002704 1526 3 E U 1 Mi 0 0 0 1002721 2798 3 E C 1 Mi 0 0 0 1002735 21 3 E U 1 Mi 0 0 0 1002735 21 7 E U 1 Mi 0 0 0 NA 3318 7 E C 0 Mo 0 1 1 285996 1962 3 E U 1 Mo 0 0 0 384789 3330 7 E C 1 Mo 0 0 1 1000757 3880 1 E U 1 Mo 0 1 1 1000815 3387 7 E U 1 Mo 0 0 0 1001373 2930 1 H U 1 Mo 0 0 0 1001455 2752 6 E C 1 Mo 0 0 0
54 AFIP # AMMPS# Bones Etiology Duration Hyperostosis Severity Cloacae Sequestrum Involucrum 1001455 2752 9 E C 1 Mo 0 0 0 1001472 3818 1 E U 1 Mo 0 1 1 1001582 3518 7 E U 1 Mo 0 0 0 1001583 3445 3 E U 1 Mo 0 0 0 1001583 3445 7 E U 1 Mo 0 0 0 1002096 3590 3 E U 1 Mo 0 0 1 1002331 3388 1 U U 1 Mo 0 1 1 1002417 1175 9 E U 1 Mo 0 0 0 1002721 2798 7 E C 1 Mo 0 1 1 1002763 1521 1 E U 1 Mo 0 0 0 26119 975 6 E U 1 S 1 1 1 26119 975 9 E U 1 S 1 1 1 285970 3141 1 E U 1 S 1 1 1 285996 1962 7 E U 1 S 1 0 1 1000090 3 E U 1 S 0 0 0 1000090 7 E U 1 S 0 0 0 1000323 2152 1 E U 1 S 1 0 1 1000617 2597 1 E U 1 S 0 0 1 1000984 2756 1 E C 1 S 0 1 1 1000989 1860 1 H U 1 S 0 0 0 1001149 4329 3 E C 1 S 0 0 0 1001149 4329 7 E C 1 S 0 0 0 1001292 2926 1 E A 1 S 1 0 1 1001465 2853 1 E C 1 S 1 1 1 1001542 3518 3 E U 1 S 0 0 1 1001845 2153 1 E C 1 S 1 0 1 1002267 2602 2 E C 1 S 1 1 1 1002312 1686 2 E C 1 S 1 0 0 1002417 1175 6 E U 1 S 1 1 1
55 AFIP # AMMPS# Bones Etiology Duration Hyperostosis Severity Cloacae Sequestrum Involucrum 1002475 3627 6 E U 1 S 0 0 1 1002475 3627 9 E U 1 S 1 1 1 1002582 3682 1 E U 1 S 0 1 1 1002667 4740 3 E C 1 S 1 1 1 1002667 4740 7 E C 1 S 1 1 1 1002669 2695 7 E U 1 S 1 1 1 1002704 1526 7 E U 1 S 1 1 1 1002738 2778 3 E A 1 S 1 0 1 1002738 2778 7 E A 1 S 1 0 1 1002750 2965 1 E C 1 S 1 1 1 NA 975 5 U C 0 U 0 1 0 NA 4333 5 U U 0 U 0 0 0 1000602 3104 2 U C 0 U 0 1 0 1000861 1581 2 U C 1 U 0 1 1 1000942 1971 2 U C 0 U 0 1 0 1001131 3284 8 U C 0 U 0 1 0 1001285 706 2 U C 0 U 0 1 0 1001288 3599 2 U C 0 U 0 1 0 1001289 476 2 U U 0 U 0 1 0 1001513 2099 8 U C 0 U 0 1 0 1001943 2212 7 U C 0 U 0 0 0 1002075 1041 2 U C 0 U 0 1 0 1002092 1582 3 E U 0 U 0 0 0 1002092 1582 7 E U 0 U 0 0 0 1002564 228 2 U U 0 U 0 1 0 1002752 4247 2 U U 0 U 0 1 0
56 Appendix D:Data and Chi-squared Results Chi-squared Test* Value Degrees of Freedom Asymp. Sig. (2-sided) Sequestrum x Severity 13.436 3 .004 Results: Involucrum x Severity 32.111 3 .000 Severity Frequency: Cloacae x Severity 41.750 3 .000 Minor 14 Etiology x Severity 60.744 6 .000 Moderate 18 Duration x Severity 9.849 6 .131 Severe 29 Etiology x Severity 9.798 4 .044 Undetermined 16
Etiology Frequency Exogenous 56 Hematogenous 5 Undetermined 16 Chi-squared Test** Value Degrees of Freedom Asymp. Sig. (2-sided) Duration Frequency Sequestrum x Severity 13.436 3 .004 Acute 28 Involucrum x Severity 32.111 3 .000 Chronic 4 Cloacae x Severity 41.750 3 .000 Undetermined 45 Etiology x Severity 4.666 2 .097 Duration x Severity 1.446 2 .485 Duration x Etiology 4.714 1 .030 *All Specimens included. ** Undetermined Specimens removed from the sample.
57 Severity Minor Moderate Severe Undetermined Total 13 11 6 15 45 Absent (8.2) (10.5) (16.9) (9.4) (45.0) 1 7 23 1 32 Present (5.8) (7.5) (12.1) (6.6) (32.0) Involucrum 14 18 29 16 77 Total (14.0) (18.0) (29.0) (16.0) (77.0)
Severity Minor Moderate Severe Undetermined Total 12 13 15 4 44 Absent (8.0) (10.3) (16.6) (9.1) (44.0) 2 5 14 12 33 Present (6.0) (7.7) (12.4) (6.9) (33.0)
Sequestrum 14 18 29 16 77 Total (14.0) (18.0) (29.0) (16.0) (77.0)
Severity Minor Moderate Severe Undetermined Total 14 18 10 16 58 Absent (10.5) (13.6) (21.8) (12.1) (58.0) 0 0 19 0 19 Present
Cloacae (3.5) (4.4) (7.2) (3.9) (19.0) 14 18 29 16 77 Total (14.0) (18.0) (29.0) (16.0) (77.0)
58 Severity Minor Moderate Severe Undetermined Total 10 16 28 2 56 Hematogenous (10.2) (13.1) (21.1) (11.6) (56.0) 3 1 1 0 5 Exogenous (0.9) (1.2) (1.9) (1.0) (5.0)
Etiology 1 1 0 14 16 Undetermined (2.9) (3.7) (6.0) (3.3) (16.0) 14 18 29 16 77 Total (14.0) (18.0) (29.0) (16.0) (77.0)
Severity Minor Moderate Severe Undetermined Total 1 0 3 0 4 Chronic (0.7) (0.9) (1.5) (0.8) (4.0) 3 5 10 10 28 Acute (5.1) (6.5) (10.5) (5.8) (28.0) 10 13 16 6 45 Duration Undetermined (8.2) (10.5) (16.9) (9.4) (45.0) 14 18 29 16 77 Total (14.0) (18.0) (29.0) (16.0) (77.0)
Etiology Exogenous Hematogenous Undetermined Total 3 1 0 4 Chronic (2.9) (0.3) (0.8) (4.0) 18 0 10 28 Acute (20.4) (1.8) (5.8) (28.0) 35 4 6 45 Duration Undetermined (32.7) (2.9) (9.4) (45.0) 56 5 16 77 Total (56.0) (5.0) (16.0) (77.0)
59 Severity Minor Moderate Severe Total 13 11 6 30 Absent (6.9) (8.9) (14.3) (30.0) 1 7 23 31 Present (7.1) (9.1) (14.7) (31.0) Involucrum 14 18 29 61 Total (14.0) (18.0) (29.0) (61.0)
Severity Minor Moderate Severe Total 12 13 15 40 Absent (9.2) (11.8) (19.0) (40.0) 2 5 14 21 Present (4.8) (6.2) (10.0) (21.0)
Sequestrum 14 18 29 61 Total (14.0) (18.0) (29.0) (61.0)
Severity Minor Moderate Severe Total 14 18 10 42 Absent (9.6) (12.4) (20.0) (42.0) 0 0 19 19 Present
Cloacae (4.4) (5.6) (9.0) (19.0) 14 18 29 61 Total (14.0) (18.0) (29.0) (61.0)
60 Severity Minor Moderate Severe Total 10 16 28 54 Hematogenous (11.9) (15.6) (26.5) (54.0) 3 1 1 5 Exogenous
Etiology (1.1) (1.4) (2.5) (5.0) 14 17 29 59 Total (14.0) (17.0) (29.0) (59.0)
Severity Minor Moderate Severe Total 1 0 3 4 Chronic (0.7) (0.9) (2.4) (4.0) 3 5 10 18 Acute (3.3) (4.1) (10.6) (18.0) Duration 4 5 13 22 Total (4.0) (5.0) (13.0) (22.0)
Etiology Exogenous Hematogenous Total 3 1 4 Chronic (3.8) (0.2) (4.0) 18 0 18 Acute (17.2) (0.8) (18.0) Duration 22 5 22 Total (22.0) (5.0) (22.0)
61