Military personnel are often subjected to physical exertion, sleep deprivation, deficient diets, overcrowding, and stress. All of these influences are capable of compromising the immune system’s ability to ward off disease-causing bacteria, thus explaining why the historical narrative of war is frequently accompanied by reports of death and suffering due to epidemics of infectious diseases. Historically some of the most common infections included: diarrhoea, dysentery, typhoid fever, gonorrhoea, and streptococcal tonsillitis. The bacteria which cause these diseases are also capable of triggering arthritis. When an arthritic condition is triggered by an infectious microbe it can broadly be referred to as “reactive arthropathy,” of which the spondyloarthritides (SpAs) are of great interest. Since the bacteria associated with these arthritic conditions are responsible for the epidemics which have plagued combatants for centuries, it is reasonable to assume that reactive arthropathy was present in past military populations. This assertion can be tested through a prevalence study of military related skeletal assemblages. To test the methodology and gain preliminary results for this research project, a pilot study was carried out using remains from the 1461 Battle of Towton. The methodology was deemed to be sound and the statistical results, while not significant, were promising.
Introduction
The physical exertion, sleep deprivation, deficient diets, and stress (both
environmental and mental) which combatants are subjected to reduces the ability of
their immune system to ward off infectious organisms (Ekblom et al. 2011). Making matters worse, the
various epidemiological backgrounds within a military group create the perfect
scenario for epidemic disaster; soldiers are assembled and deployed into disease
environments to which their immune systems are not acclimatized, making them more
susceptible to unfamiliar pathogens (Smallman-Raynor
and Cliff 2004). Further influencing the overall health of military
combatants is the fact that wartime leads to overcrowding, unsanitary living
conditions, the collapse of social infrastructures like healthcare facilities, and a
breakdown of the normal rules of social conduct (Smallman-Raynor and Cliff 2004).
The connection between the military lifestyle and infectious disease continues in
spite of modern medical knowledge, but it can certainly be said that the impact of
infectious diseases would have been greater among past combatants due to poor
sanitation practices and limited treatment options. Diseases that were commonly
found among past combatants included diarrhoeal diseases, venereal diseases, and
laryngopharynx infections (Smallman-Raynor and Cliff
2004). These conditions are frequently triggered by bacteria, including:
(diarrhoeal) Salmonella enteritidis, Campylobactera jejuni, Yersinia
enterocolitica, Shigella dysenteriae, Shigella flexneri, Escherichia coli,
Salmonella typhi, Clostridium difficile, (venereal) Neisseria
gonorrhoeae, Chlamydia trachomatis, (laryngopharynx)
Streptococcus pyogenes, and Streptococcus
pneumoniae (Carter 2010; Chandran and Raychaudhuri 2010; Ehrenfeld 2012; Hannu 2011).
These bacteria are known to be arthritogenic, meaning they are capable of triggering
an arthritic reaction. When an arthritic reaction occurs as a result of an
infectious agent, the condition can be broadly labelled as reactive arthropathy. Of
the various forms of reactive arthropathy, the spondyloarthritides (SpAs) are of
great in relation to past military populations since they are linked to the bacteria
previously mentioned as common among past combatants; Reactive Arthritis (ReA) is
associated with the diarrhoeal and venereal bacteria and Psoriatic Arthritis (PsA)
with streptococcal bacteria (Barton and Ritchlin
2005; Carter 2010; Chandran and Raychaudhuri 2010).
Since combatants have historically had a higher exposure and susceptibility to
arthritogenic bacteria, it is reasonable to assume that the resulting conditions,
such as SpAs, could be found in past military populations at a higher frequency than
non-military populations. To test this assumption, a project was designed for a
palaeoepidemiological prevalence study to be carried out on multiple military
assemblages from conflicts of various centuries; these military assemblages would
then be compared to control assemblages to identify if disease patterns differed due
to contrasting lifestyles (military versus non-military). The first assemblage
examined, the Towton assemblage, was utilized as a pilot study intended to: 1)
compare a military and non-military assemblage for contrasting and/or consistent
patterns in erosive conditions using simple statistics, 2) evaluate the
effectiveness of the applied methodology, and 3) identify and modify issue with the
designed methodology before applying it to larger assemblages.
Material: The Towton Assemblage
The War of the Roses (1455–1487) was a dynastic dispute between the House of
Lancaster (Duke of Somerset) and the House of York (Duke of York). One notable
battle occurred in 1461 outside the village of Towton. Chroniclers of the period
recorded approximately 28,000 fatalities, but this figure is likely exaggerated
based on archaeological research and closer examination of primary resources; a more
accurate figure would likely be closer to 3,000 men (Sutherland 2009, 22; Boardman
2007). No matter the true number, the battle was won by the Yorkists and
Edward IV became the King of England (Goodwin
2012).
In 1996, not far from the Towton battlefield, construction workers uncovered several
sets of human remains in one mass grave (Fiorato
2007). At the end of the excavation, a total of 38 individuals were
recovered (Boylston et al.
2007). The remains were examined by bioarchaeologists at the University
of Bradford and they determined that the individuals were males aged 16–60+
(Boylston et al. 2007;
Burgess 2007). There was a high
prevalence of perimortem trauma (around the time-of-death) in the assemblage that
would have been made by blades and blunt force (Novak 2007). The proximity to the battlefield, nature of the burial,
biological profile of the remains, and archaeological artifacts all suggested that
the skeletal remains were likely casualties of the 1461 Towton engagement (Burgess 2007).
The Men of Towton: Medieval Armies and Military Lifestyle
The early medieval period was the age of “feudal warfare,” which
means the primary method of enlisting men was through obligatory service.
Vassals were obligated to devote 40 days of military service per year, without
monetary return (Bentley 1997, 204; Goodwin 2012). This system meant armies
were disorganized and made up of men with limited military experience (Goodwin 2012).
By the time the War of the Roses began in the 15th century, problems with
military organization had improved greatly. Society was still loosely
feudalistic (bastard feudalism), but improvements in “bureaucracy”
and “techniques of literate administration” led to a more
professional army (Goodwin 2012, 16).
Emphasis on the importance of governmental administrations meant that one of the
primary means of enlisting men in the late medieval period utilized legal
contractual agreements where lords provided land or monetary reimbursement for a
vassal’s allegiance and military assistance upon request (Goodwin 2012, 124; Gravett 2002, 14). Many of these vassals would have been
proficient military men with training, such as knights, mercenaries, and
men-at-arms (who were often kept as retainers by nobles or knights) (Bell et al. 2013; Goodman 2006; Goodwin 2012). Outside of these contractual agreements,
English commoners were also enlisted through active campaigning carried out by
influential members of society (magnates, gentlemen, and religious leaders) who
had the connections, wealth, and charisma needed to convince people to take up
arms (Goodwin 2012, 18–19). In sum,
the men who fought in the War of the Roses would have been from mixed social and
economic backgrounds, with varied degrees of military experience.
Increased emphasis on contractual agreements amplified the ability to tax
subjects on a large scale, which allowed military operations to become larger
and more organized (Goodwin 2012, 17).
Despite these new advantages, armies were still very expensive and difficult to
supply for extended periods of time, so campaigns during the War of the Roses
continued to be relatively short endeavors that occurred during the winter when
farming was not at its peak (Goodwin
2012). This means that late medieval armies are unique when compared with
modern standing armies; standing armies would have been placed under the
strenuous conditions of the military lifestyle for extended periods of time, but
medieval armies would have been exposed to these condition in short bursts.
Though the period of exposure would have been shorter for medieval armies, the
struggles would have been much the same: overcrowding, unsanitary/inadequate
living conditions, and being undersupplied (Royle 2008). Indeed, fatal diseases did occur among armies during
the War of the Roses. For instance in the summer of 1485, a highly fatal
infection labeled as the “English sweating sickness” took hold
across England. Whether this disease originated within the army is debated, but
nearly 50 years after the outbreak of the disease, Polydore Vergil wrote that
the disease first appeared in August of 1485 among the French mercenary army of
Henry VII (Sadler 2013, 16; Smallman-Raynor and Cliff 2004, 81).
Suitability of the Towton Assemblage for a Pilot Study
Despite the fact that medieval armies do not fit the traditional concept of a
standing army, issues such as overcrowding and unsanitary conditions were still
recorded among 15th century armies, along with outbreaks of disease (Sadler 2013; Smallman-Raynor and Cliff 2004). For this reason, it was
decided that examination of the Towton assemblage would still be appropriate. It
was further speculated that this distinction would later prove to be an
interesting comparison for the military assemblages obtained from 18th- and
19th-century conflicts. Outside of the historical background of this assemblage,
the small number of individuals in the Towton assemblage made it ideal for a
pilot study.
Findings in the Towton Assemblage
Overall, 6 skeletons had EA (3 unspecifiable EA, 3 SpAs). The skeletons assigned to
the SpA categorization were of particular interest. The SpA skeletons shared
characteristics commonly observed in ReA, but not to the extent that they fulfilled
all of the criteria needed to meet the ReA operational definition. Nevertheless,
they provided enough evidence to strongly suggest the pattern of the
condition’s course had it been able to continue its development. Though they
cannot be categorized as ReA, the amount of supporting evidence indicated that some
informal categorization beyond the general SpA classification should be used. These
cases were thus identified as “Early ReA”, which simply delineates that
these skeletal individuals seem to follow the patterning of ReA more than the
alternative SpAs. The following sections provide a brief description of all the EA
observed in the Towton assemblage.
Unspecifiable EA: Towton 25, 41, and 50
Towton 25 had two erosions. The first erosion was on the right first metatarsal
on the distal end, medial surface. This erosion was para-articular, round, and
deep. The walls were made of thickened and smooth trabecular bone. The second
erosion was on the right scaphoid. This erosion was round and marginal, with
uneven scalloped margins. The interior surface of this erosion exposed irregular
and dense trabecular bone. These characteristics were not enough to clearly
understand the nature of these erosions.
The skeleton of Towton 41 had erosions on the distal end of the right fifth
proximal phalanx. These erosions were marginal and made of irregular bone on the
para-articular lateral surface. This was the only location where erosions were
observed, but the erosive changes were extensive and eroded enough bone to
distort the natural shape of the joint margin. Once again, these erosions were
not characteristic enough to be categorized beyond the EA categorization.
Towton 50 was the last skeleton to have unspecifiable EA. Two of the erosions
were suspect since they were not characteristic of what is normally observed in
EA or pressure lesions such as bunions. These lesions occurred on the distal end
of the right and left first metatarsals on the medial surface. The holes were
deep and round in shape with the interior walls being made of dense trabecular
bone. The lesion on the left metatarsal had an overhanging bridge of bone around
the margin, but it did not appear to be a Martel hook as would be seen in gout.
Though these mystery lesions could not be easily identified as true erosions,
clearly defined erosions were also present. The first true erosion was observed
on the superior surface of the right navicular. Finally, erosions were observed
on the distal end of the left second proximal phalanx and affected the margins
of both the medial and lateral surface and was accompanied by subcortical
resorption on the joint surface.
SpAs: Towton 8, 9, and 13
The first skeleton fitting with the SpA classification was Towton 8 (see Fig.
1), which had several foot erosions,
characteristic bone formation in the feet, and sacroiliac joint involvement. The
focus of the erosions and bone formation in the feet is suggestive of ReA, but
minimal spinal involvement and lack of sacroiliac joint fusion prevented
confident diagnosis based on the operational definition. Two vertebrae (L1 and
S1) both had para-vertebral bone formation that seemed more characteristic of
ossification of ligamentous tissue than the marginal osteophytes observed in
spinal degeneration; the surface of the vertebral body did not show pitting and
the bone growth originated inferior to the joint’s true margin. The foot
erosions affected numerous elements, including: the distal end of the left fifth
proximal phalanx (also associated with ankylosis of the distal interphalangeal
joint), the distal end of the left fourth intermediate phalanx, the distal end
of the left first proximal phalanx, and the inferior margin of the right
navicular. In addition to these erosions, both the right and left shaft of the
fifth metatarsals had ReA-characteristic entheses associated with the plantar
interossei muscle. Lastly, there was unilateral sacroiliitis of the right
sacroiliac joint, which was defined by: marginal erosions on the sacrum
(superior), an area of subcortical resorption on the joint surface, and lipping
suggestive of early ossification of the anterior sacroiliac ligament.
Figure 1
Figure 1
Pictured and labeled above are examples of the erosions, bone formation,
and sacroiliitis observed in Towton 8 which led to the diagnosis of
“SpA” and “Early ReA”. Entheses can be seen in
the fifth metatarsal and erosions were observed in the right navicular,
left fifth proximal phalanx, left fourth intermediate phalanx, and right
sacrum. The sacrum images show marginal erosions (above) and subcortical
erosions (below). Source: photos taken courtesy of BARC, arranged by
author.
Towton 9 also fit the SpA classification (see Fig. 2) and was characterized by: extensive lower limb enthesopathy,
asymmetric fusion of three consecutive thoracic vertebrae (T6-T8), ligamentous
ossification in T9 –T12, sacroiliitis, and small erosions in the feet. The
lower limb enthesopathy and small erosions in the feet are characteristic of
ReA, but the spinal fusion did not have observable skip lesions (unfused
vertebrae separating segments of fused vertebrae). Though there were no skip
lesions, the pattern of ligamentous ossification in several other vertebrae
suggested that further fusion may have eventually occurred. Though sacroiliac
joint fusion was not observed in Towton 9, bilateral sacroiliitis was present
and defined by enthesopathy of the anterior sacroiliac ligament and a thin layer
of porous bone growth on the joint surface.
Figure 2
Figure 2
Pictured and labeled above are examples of the erosions, spinal fusion,
bone formation, and sacroiliitis of Towton 9 which led to the diagnosis
of “SpA” and “Early ReA”. Enthesopathy shown in
this image includes the anterior sacroiliac ligament in the left sacrum,
the lesser trochanter of the femur, soleal line of the tibia, the distal
fibula, tubercle of the fifth metatarsal, and the navicular. Erosions
affected a proximal and intermediate phalanx of the right foot. Fusion
in T6-T8 vertebrae and ligamentous growth in the T9-T12 vertebrae was
also observed. Source: photos taken courtesy of BARC, arranged by
author.
The final SpA identified was Towton 13 (see Fig. 3). The features used to categorize Towton 13 were: enthesopathy
(primarily in the lower limbs), left and right para-vertebral ligamentous
ossification in several thoracic vertebrae (T7 –T12) suggestive of
eventual fusion, sacroiliitis, and small erosions in the feet. Once again, lower
limb enthesopathy and erosions are a distribution pattern seen in ReA. This
pattern was observed in Towton 13 apart from entheses on the humeri. The
erosions observed in Towton 13 occurred in the left foot, including the distal
end of the first metatarsal and the distal end of the second proximal phalanx.
Though there was no spinal fusion in Towton 13, ligamentous growth was observed
in the left and right para-vertebral position and was suggestive of eventual
fusion most characteristic of ReA or PsA; the position of the bone growth
observed in the spine is not characteristic of the anterior fusion seen in cases
of AS and was not characteristic of the bone growth seen in Diffuse Idiopathic
Skeletal Hyperostosis (DISH), which is confined to the right side in the
thoracic region of the vertebral column (Waldron
2009). The sacroiliac joint was not fused in Towton 13, but
sacroiliitis was present and defined by bilateral growth in the anterior
sacroiliac ligament and pitting on the joint surfaces.
Figure 3
Figure 3
Pictured and labeled above are examples of the erosions, bone formation,
and sacroiliitis of Towton 13 which lead to the diagnosis of
“SpA” and “Early ReA”. Though there was no
spinal fusion, there was well developed ligamentous growth observed in
the thoracic and lumbar spine. Sacroiliitis was also present in both the
left and right sacroiliac joint. Enthesopathy was observed in numerous
locations, including the linea aspera in the femur, calcaneum, and
tubercles of the left and right fifth metatarsals. Erosions were
observed in the left first metatarsal and the left second proximal
phalanx. Source: photos taken courtesy of BARC, arranged by author.
Prevalence Analysis and Discussion
The results of the prevalence analysis for both assemblages can be seen in Table
2 and Fig 4. In Table 2 it should be noted
that any conditions not mentioned were absent (prevalence 0 percent). Since the
pathology observed in control skeleton 3114 was debatable, if one chose to analyse
it as a SpA instead of EA, the prevalence would be the same as currently presented
in Table 2; both n and N would be the same.
For this same reason, Fig 4 not only compares
the overall EA statistics for Towton and the control, but also the data for the SpAs
identified in the Towton assemblage.
Table 2
This table shows the prevalence of erosive conditions in the Towton and All
Saint’s assemblages.
| Prevalence of Erosive Arthropathy in
the Towton Assemblage |
|
|
| Broad Classifications |
Grouping |
n |
N |
Prevalence (95% CI) |
|
|
| Overall EA (including
SpA) |
“Comprehensive Prevalence” |
6 |
38 |
15.8% (7.4–30.4) |
| Excluding “Poor” Preservation |
6 |
26 |
23.1% (11.0–42.1) |
| Excluding “Poor/Moderate” Preservation |
6 |
22 |
27.3% (13.2–48.2) |
| EA (excluding
SpA) |
“Comprehensive Prevalence” |
3 |
38 |
7.9% (2.7–20.8) |
| Excluding “Poor” Preservation |
3 |
26 |
11.5% (4.0–29.0) |
| Excluding “Poor/Moderate” Preservation |
3 |
22 |
13.6% (4.7–33.3) |
| SpA |
“Comprehensive Prevalence” |
3 |
38 |
7.9% (2.7–20.8) |
| Excluding “Poor” Preservation |
3 |
26 |
11.5% (4.0–29.0) |
| Excluding “Poor/Moderate” Preservation |
3 |
22 |
13.6% (4.7–33.3) |
| Specific
Classifications |
Grouping |
n |
N |
Prevalence (95% CI) |
|
|
| “Early”
ReA |
“Comprehensive Prevalence” |
3 |
38 |
7.9% (2.7–20.8) |
| Excluding “Poor” Preservation |
3 |
26 |
11.5% (4.0–29.0 ) |
| Excluding “Poor/Moderate” Preservation |
3 |
22 |
13.6% (4.7–33.3) |
| |
| Prevalence of Erosive Arthropathy in
the Control Assemblage |
|
|
| Broad Classifications |
Grouping |
n |
N |
Prevalence (95% CI) |
|
|
| Overall EA |
“Comprehensive Prevalence” |
1 |
35 |
2.9% (0.5–4.5) |
| Excluding “Poor” Preservation |
1 |
28 |
3.6% (0.6–17.7) |
| Excluding “Poor/Moderate” Preservation |
1 |
22 |
4.5% (0.8–21.8) |
Figure 4
Figure 4
This table compares the data from the Towton (black squares) and All
Saint’s (gray triangles) assemblages. Towton had more examples of
overall EA; 6 skeletons, 3 of which were classified as SpAs. The control
assemblage had 1 skeleton with EA which could possibly represent a SpA. The
confidence intervals overlap, meaning the results are not statistically
significant, but this may be due to the small number of individuals.
The confidence intervals overlap in Fig 4,
meaning the results are not statistically significant, but the small sample size has
expanded the 95 percent confidence intervals making the table a bit deceiving.
Though not significant, the prevalence is still notably higher in the Towton
assemblage; over five times that of the control sample. The presence of six skeletal
individuals (15.8 percent prevalence) fitting the criteria for an “overall
EA” classification in the Towton assemblage is a striking figure compared to
the control which had only one skeleton (2.9 percent prevalence) fitting the defined
criteria.
As mentioned in the methodology section, preservation was considered as a means of
including and excluding skeletons from the study. These figures are also presented
in Table 2. Considering the “overall
EA” figures for Towton and the control group, Towton’s lowest possible
accounting of individuals has a prevalence of 27.3 percent and the highest
accounting would be 15.8 percent. The control’s lowest possible accounting of
individuals would be a prevalence of 4.5 percent and the highest possible accounting
would be 2.9 percent. This equals a difference of 12.9–22.8 percent between
the two assemblages.
The Towton assemblage had three skeletons fitting the criteria for a SpA
classification with the lowest possible accounting of individuals being 13.6
percent, and the highest possible accounting being 7.6 percent. This is also a
prominent figure when compared to the control. Even if we entertain the idea that
the EA found in the control sample was indeed a SpA (not gout combined with DISH),
the comparative prevalence would be 4.5 percent with the lowest possible accounting
and 2.9 percent with the highest accounting. This equals a difference of
4.7–9.1 percent for the “SpA” classification of the two
assemblages. Of comparative interest, Arriaza 1993 reported a similar SpA prevalence
of 4.4–7.4 percent in a skeletal assemblage from Chile; Arriaza noted that
this was a high prevalence which could indicate that the population was prone to
outbreaks of infectious diseases.
Of the three skeletons with unspecifiable EA in the Towton assemblage, none appeared
characteristic of gout or erosive OA, which are the only forms of EA that are not
reactive suspects; therefore, all of the EA observed in the Towton assemblage may
have been reactive to bacterial triggers. Being more cautious, the skeletons
classified as having SpAs can certainly be considered as reactive based on modern
clinical research (Carter 2010; Chandran and Raychaudhuri 2010; Ehrenfeld 2012; Hannu 2011). Taking this a step further, the spinal fusion, pattern of
erosions, and distribution of enthesopathy in the Towton SpAs appeared to be most
characteristic of ReA. If these instances were indeed underdeveloped ReA, a list of
potential bacterial triggers could be provided, which would include bacteria of the
Urogenital (Chlamydia and N. gonorrhea) and
Gastrointestinal (Salmonella enteritidis, Campylobactera jejuni, Yersinia
enterocolitica, Shigella dysenteriae, Shigella flexneri, Escherichia
coli and Clostridium difficile) variety (Carter 2010); therefore, the presence of such
pathology provides an idea of the potential diseases this group of combatants
potentially encountered at some point during their military service. This is an
interesting line of reasoning since these bacterial diseases do not cause direct
skeletal changes and are infrequently discussed by bioarchaeologists for this reason
(Roberts and Manchester 2010; Waldron 2009), but SpAs provide an indirect
method of discussing these infections in skeletal material. For instance, the
results from the Towton assemblage supports what was already suspected according to
clinical research and historical documentation, that at least some of the bacterial
agents which trigger SpAs were present in military populations as far back as the
15th century.
An interesting pattern which emerged from this pilot study was a bias for individuals
with EA to fall into the “Upper Middle Adult” category. Towton 50 was
unable to be assigned an age beyond “Adult”, but of the remaining
skeletons with relevant pathology, 4 were Upper Middle Adults and 1 was a Lower
Middle Adult. In the control assemblage, the 1 confirmed EA was also an Upper Middle
Adult. This pattern may or may not continue in collections yet to be examined, but
the pattern is markedly established in the Towton assemblage. A potential
explanation for this pattern is that the older individuals may have contracted a
bacterial agent earlier in life, which would mean the disease had more time to cause
observable changes to the skeleton.
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