Table Of ContentR. K. Chhem · D. R. Brothwell
Paleoradiology
R. K. Chhem · D. R. Brothwell
Paleoradiology
Imaging Mummies and Fossils
With 390 Figures and 58 Tables
123
Don R. Brothwell, PhD
Department of Archaeology
The University of York
The King’s Manor
York Y01 7EP
UK
Rethy K. Chhem, MD, PhD, FRCPC
Department of Diagnostic Radiology and Nuclear Medicine
Schulich School of Medicine and Dentistry
University of Western Ontario
London Health Sciences Centre
339 Windermere Road
London, Ontario
N6A 5A5
Canada
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Foreword
The Radiologist’s Perspective
It is my pleasure to write the foreword to this groundbreaking text in paleoradiol-
ogy. Dr. Rethy Chhem is a distinguished musculoskeletal radiologist, and he is the
founder of the Paleoradiologic Research Unit at the University of Western Ontario,
Canada, and the Osteoarchaeology Research Group at the National University of
Singapore. His special area of paleoradiologic expertise is the Khmer civilization
of Cambodia, and his contributions to radiologic and anthropologic science have
built bridges between these two not always communicative disciplines.
Dr. Don Brothwell is of course well known to the paleopathology communi-
ty. He is something of an anthropologic and archaeologic polymath, having made
important contributions to dental anthropology, the antiquity of human diet,
and veterinary paleopathology, among others. His textbook, “Digging Up Bones”
(Brothwell 1982), has introduced many generations of scholars to bioarchaeology,
a discipline of which he is one of the founders. It is only fitting that this book is
the work of a radiologist and an anthropologist, both of whom have experience in
musculoskeletal imaging and paleopathology. For more than 100 years, diagnostic
imaging has been used in the study of ancient disease. In fact, one of the first com-
prehensive textbooks of paleopathology, “Paleopathologic Diagnosis and Interpre-
tation,” was written as an undergraduate thesis by a nascent radiologist, Dr. Ted
Steinbock (Steinbock 1976).
The advantages of diagnostic imaging in paleopathologic research should be
intuitively obvious. Osseous and soft tissue may be noninvasively and nondestruc-
tively imaged, preserving original specimens for research and display in a museum
setting. Not only will the original material, often Egyptian mummies, be preserved
for future generations of researchers, but public enthusiasm will be fostered by the
knowledge that we can see what is really underneath all those wrappings. Recent
advances in computed multiplanar image display present novel ways to increase
our understanding of the individuals, the processes of mummification and burial,
and the cultural milieu in which these people lived. Unfortunately, although the
potential of radiology has been recognized, the realization of collaborative effort
has been inconsistent.
The earliest use of radiography in paleopathology was in the diagnosis of specific
diseases in individuals, much as it is in clinical medicine today. Egyptian mummies
were radiographed as early as 1896. Comprehensive studies of mummy collections
were performed in the 1960s and 1970s, culminating in the exhaustive treatise by
Harris and Wente, with important contributions by Walter Whitehouse, MD, in
1980 (Harris and Wente 1980). The usefulness of radiologic analysis of collections
of such specimens led to the realization that diagnostic imaging has important im-
plications in paleoepidemiology as well as in the diagnosis of individual cases.
Technical innovations in radiology have paralleled progress in paleopathology.
We are now able to perform per three-dimensional virtual reproductions of the
facial characteristics so that mummies do not have to be unwrapped, and we can
now carry out “virtual autopsies” using three-dimensional computed tomography
as a guide. We are now also using modern imaging technology to go beyond pic-
VI Foreword
tures. It is well established that radiologic and computed tomographic evaluation,
in conjunction with physical anthropologic and orthopedic biomechanical data,
may yield important biomechanical information in such studies as noninvasive
measurement of the cross-sectional area of long bones to compare biomechanical
characteristics in different populations such as hunter-gatherers and agricultura-
lists, and to study the mechanical properties of trabecular bone.
This textbook represents a significant advance in the effort to engage clinical
physicians, especially radiologists and paleopathologists in a dialogue. Although
there have been many such attempts in the past, they have for the most part dealt
with specific imaging findings to diagnose disease in specific ancient remains.
Chhem and Brothwell have given us the opportunity to go beyond this type of ad
hoc consultation by presenting a systematic approach to the radiologic skeletal dif-
ferential diagnosis of ancient human and animal remains. However, I believe that
the intent of the authors is not so much to have paleopathologists interpret these
finding in a vacuum, but rather to understand the capabilities of musculoskeletal
radiologists, not only to assist with diagnosis, but also to offer information about
the clinical setting in which these diseases occur and to suggest other appropriate
imaging technology. For their part, musculoskeletal radiologists should be able to
use this text to understand the context in which paleopathologists work, including
taphonomic change, and to appreciate the rich legacy of diagnostic imaging in bi-
ological anthropology and archaeology.
Along with the authors, I hope that radiologists and biological anthropologists
will use this textbook to translate both the radiologic and anthropologic idiom
to better comprehend the other’s potential for collaboration. Once we establish a
common language, it will be easier to solve the diagnostic problems and dilemmas
we share. Doctors Chhem and Brothwell are to be congratulated for taking that
important first step.
Ethan M. Braunstein
References
Brothwell DB (1982) Digging up Bones (3rd edn). Cornell University Press, Ithaca
Steinbock RT (1976) Paleopathologic Diagnosis and Interpretation. Charles C. Thomas, Spring-
field, Illinois, p 423
Harris JE, Wente EF (1980) An X-Ray Atlas of the Royal Mummies. University of Chicago Press,
Chicago, Illinois, p 403
Foreword
The Anthropologist’s Perspective
The study of human paleopathology has benefited from the use of radiological
methods for many decades. However, the use of radiological images and interpreta-
tive insights has in earlier years tended to be limited to medical professionals with
expertise and experience in interpreting radiographic images as well as having ac-
cess to the necessary equipment to produce radiographs in the hospitals where they
worked. As the diagnostic value of radiology in the evaluation and diagnosis of
disorders in archaeological human and nonhuman remains became more appar-
ent, plain-film radiological facilities were established in many nonmedical centers
where research on these remains was a central part of their scientific endeavors.
With greater access to radiographic data on paleopathological specimens, biologi-
cal anthropologists became increasingly competent in interpreting these images.
However, there remain very important reasons why ongoing collaboration between
radiologists and biological anthropologists in the analysis of paleopathological cas-
es continues to be a valuable contribution to science.
One of the troublesome limitations of plain-film radiology is that three-dimen-
sional anatomical features are projected onto a single plain. The inevitable super-
imposition that occurs can obscure important details of a radiographic image,
adding to the challenge of interpretation. With the advent and widespread use of
computed tomography (CT) radiological methods as an important diagnostic tool
in clinical radiology, these methods began to be applied to archaeological remains.
Among other advantages, CT imaging virtually eliminates the problem of super-
imposition. However, access to CT technology by paleopathologists, unless they
are also radiologists, is often inconvenient or beyond the limited budgets of many
researchers. This limitation in the use of CT imaging is changing as more facilities
with CT equipment are available, including some in nonmedical research institu-
tions. The remarkable power of CT imaging has made this mode of radiological
investigation an important tool for the paleopathologist.
During my collaborations with radiologists in my own research on human skel-
etal paleopathology during the past 40 years, several issues have been highlighted.
One is the need for better specimen positioning in taking radiographs of archaeolo-
gical human remains. In clinical radiology, great attention is paid to the orientation
of the anatomical site to be imaged relative to the axis of the X-ray beam. Clinical
radiographic technicians receive careful training in the placement of the patient to
be radiographed. Positioning of paleopathological cases of disease is often a helter-
skelter arrangement in which little attention is paid to the anatomical relationship
between multiple bones or the anatomical position relative to a living person. The
emphasis is often on getting as many bones as possible on the X-ray film to save
expense. Such a procedure does not lend itself to taking full advantage of the vast
knowledge and experience of radiologists in the diagnosis of skeletal disorders.
Another problem is that in the burial environment, soil constituents often pene-
trate archaeological human skeletal remains and can pose real challenges in diag-
nosis, particularly for those inexperienced in recognizing these infiltrates. Soil in-
filtrates are denser than bone and appear as sclerotic areas in radiographic images.
VIII Foreword
These areas can be confused with antemortem pathology. Postmortem degradati-
on of bone also occurs in the burial environment from both the acidic conditions
commonly encountered in soil and the action of organisms, including bacteria,
fungi and insect larvae, and plant roots. These destructive processes can mimic
osteolytic pathological processes. Very careful attention to the fine details of the
margins of destructive defects in bone is necessary to resolve the question of ante-
versus postmortem destruction.
In interpreting radiographs of skeletal remains curated in museums, there is the
further complication of distinguishing between substances added during museum
curation of archaeological remains and antemortem pathological processes. For
example, the glue used to repair breaks in older museum accessions can be very
dense and create an appearance of a sclerotic response or a bone tumor in a radi-
ograph.
These examples highlight the importance of collaboration between the clinical
radiologist with an interest in paleopathology and the biological anthropologist
in any study of archaeological remains, including mummified tissues and skeletal
remains. Each discipline brings a specialized knowledge of the subject that maxi-
mizes the quality of the interpretation of radiological images from archaeological
remains, both human and nonhuman.
Although collaboration between radiologists and biological anthropologists is
an obvious strategy, the increasing use of radiology in the study of archaeological
biological tissues calls for an explicit statement regarding the use of this methodo-
logy in research. As indicated above, the radiology of archeological remains poses
special problems, and these need to be identified and resolved to ensure that radio-
graphic data on such remains is interpreted correctly. There is a very real need for
an authoritative reference work that will provide the insight from both anthropo-
logy and radiology as this relates to the use of radiological methods in the study of
ancient evidence of disease.
I am very pleased to learn about the collaborative effort between Dr. Rethy
Chhem, a skeletal radiologist, and Dr. Don Brothwell, a biological anthropologist,
to produce a book on the radiology of archaeological biological tissues. Both are
distinguished international authorities in their respective disciplines. In addition,
both bring a depth of experience in the study of paleopathology that ensures ca-
reful coverage of the subject and new insight into the technical, theoretical, and
interpretative issues involved in the application of radiology to the evaluation and
diagnosis of abnormalities encountered in the analysis of human and nonhuman
archaeological remains. I am confident that this book will be a major milestone in
the study of disease in human and nonhuman archeological as well as paleontolo-
gical remains.
Donald J. Ortner
Preface
This book arose from chance meetings and discussion between the two of us, one a
radiologist and anthropologist (RC), the other a bioarchaeologist and paleopathol-
ogist (DB). The former expressed his interest in developing a scientific field that
combined radiology with anthropology, especially bioarchaeology and paleopa-
thology. The latter agreed completely that the subjects of radiographic techniques
and the application of all aspects of medical imaging to the study of anthropological
materials were sadly neglected. At the same time, both recognized that a publica-
tion was needed to show more clearly the considerable potential of paleoradiology.
At this point, one of us (DB) expressed some uncertainty about finding the time (if
not the mental strength) to contribute to the formation of this field. However, the
extreme enthusiasm and persuasiveness of his friend and colleague (RC) resulted
not in his withdrawal, but in discussing a joint plan of action. Such is the power of
an enthusiastic colleague and a challenging project!
What follows in these pages is an attempt to introduce a new field of academic
study that is concerned with the value of applying X-rays to a broad range of bio-
anthropological materials, from human remains to other animals and even plants.
We would emphasize that brought together in this way, it becomes a new field, even
if components of the whole field have a much longer history. An entire chapter
deals with the use of paleoradiology as a diagnosic method of ancient diseases. So
in its entirety, the book is a pilot survey, an introduction to a broad-based subject
that we feel is going to expand and interest a growing number of our colleagues,
spanning human and veterinary radiology, anthropology (especially bioarchaeolo-
gy), zoology, and botany. It is clear that at the present time, the literature relevant
to this broad discipline is highly variable, and to some extent locked away in spe-
cialist publications. There is currently a strong bias toward human remains, both
skeletal and mummified. We predict that this will change, and in particular we
suggest that it will be employed increasingly in the field of zooarchaeology, where
considerable numbers of bones and teeth are processed annually throughout the
world and increasing attention is being paid to reconstructing the health status of
earlier animal populations.
We sincerely hope that this introductory text on paleoradiology will stimulate
interest in our colleagues, sufficient for them to ponder how they might contribute
to this field in the future, or at least bring it to the notice of their colleagues or
students. We do not see paleoradiology as a marginal and somewhat exotic occup-
ation, rather one of considerable academic potential.
Rethy K. Chhem and Don R. Brothwell
Acknowledgements
We wish to express our great appreciation to our many friends and colleagues who
have assisted in the preparation of this book in many ways. We sincerely hope that
this list is complete, but if we have overlooked anyone by mistake, we ask for their
forgiveness.
Supporting Rethy Chhem: Gord Allan, Ian Chan, Ghida Chouraiki, Eadie
Deville, Jillian Flower, Jill Friis, Bertha Garcia, John Henry, Carol Herbert, Da-
vid Holdsworth, Cheryl Joe, Stephen Karlik, Karen Kennedy, Jodie Koepke, Kyle
Latinis, Luy Lida, Julian Loh, Liz Lorusso, Jay Maxwell, David McErlain, Wendy
McKay, El Molto, Andrew Nelson, Jeremy O’Brien, Katie Peters, Christophe Pot-
tier, Lisa Rader, Janine Riffel, Cesare Romagnoli, Frank Rühli, Roberta Shaw, Wang
Shi-Chang, Vankatesh Sudhakar, Cynthia Von Overloop, Corie Wei, Jackie Wil-
liams, Deanna Wocks, Kit M. Wong, Eric Yap, Anabella Yim, and members of the
Osteoarchaeology Research Group of Singapore.
Supporting Don Brothwell: Trevor Anderson, John Baker, Keith Dobney, Ben
Gourley, Deborah Jaques, Simon McGrory, Theya Molleson, Naomi Mott, Sonia
O’Connor, Terry O’Connor, Ian Panter, Jacqui Watson, Wyn Wheeler
We wish to thank GE Healthcare Canada for their support to the Paleoradiology
Research Unit, and the Department of Radiology, London Health Sciences Centre
and the University of Western Ontario, Canada.
Finally, but by no means least, we both wish to thank Sirika Chhem and Jade
Orkin-Fenster, whose hard work and commitment in York during the summer of
2005 provided us with a wide range of digital radiographs for use in this book.
