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Biocultural Variation of Skeletal Trauma in Contemporary Greeks


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BIOCULTURAL VARIATION OF SKELETAL TRAUMA IN CONTEMPORARY GREEKS By SUZANNE MARIE ABEL A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2004

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Copyright 2004 by Suzanne Marie Abel

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iii ACKNOWLEDGMENTS I thank my committee members Drs. Anthony Falsetti, Michael Warren, Sue Boinski, and Thomas Hollinger for their help in making this dissertation possible. They each provided necessary support in one way or another, and I greatly admire their individual talents in anthropology and anatomy. This research was funded in part by Univ ersity of Florida Foundation grants, the William R. Maples Memorial Scholarship, and by Drs. Anthony Falsetti and Michael Warren. My parents Vernon Abel, Gerry Buchanan and Joyce Buchanan have given me 35 years of love, emotional support and financial help, for which I am eternally grateful. Somehow they knew I would stick with it and finish, even when I was unsure. I thank Dr. Sotiris Manolis for allowing me access to the skeletal collections at the University of Athens and for his gracious hospitality. Constantine Eliopoulos provided daily camaraderie in the lab while making the best coffee in all of Greece over a simple lab burner. Anna Lagia also offered valuable information a bout the skeletal collections. I would like to thank all the citizens of Gr eece I met during my time in their country. They are truly peerless in th eir warmth and hospitality. Stateside, I thank Dr. Ted Rathbun, whose infective enthusiasm about anthropology and teaching changed my life. Anyone who has had the pleasure of meeting Ted knows there is no one else lik e him. HK forever!

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iv This dissertation could not have been done were it not for Ann Ross, Katie Jemmott, and the rest of the CAPHIL gang. I thank them for their faithful support, the Halloween parties and the times we sat around the lab and commiserated. Last but certainly not least, I thank Dr. Wolf Bueschgen. He was my classmate and fellow traveler years ago, and he continues to travel with me through life now as my husband. What patience he possesses to put up with me.

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v TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iii LIST OF TABLES............................................................................................................vii LIST OF FIGURES...........................................................................................................ix ABSTRACT....................................................................................................................... ..x CHAPTER 1 INTRODUCTION........................................................................................................1 2 MECHANISMS OF SKELETAL TRAUMA..............................................................5 Childhood Trauma........................................................................................................5 Child Abuse..................................................................................................................7 Adult Trauma................................................................................................................9 Interpersonal Violence................................................................................................12 3 RELEVENT BIOARCHAEOL OGICAL LITERATURE.........................................14 Skeletal Trauma Studies Using Greek Collections.....................................................16 Franchthi Cave............................................................................................................16 Catal Huyuk................................................................................................................17 Lerna.......................................................................................................................... .18 Khirokitia....................................................................................................................1 9 Karatas........................................................................................................................ 20 Cephallenia.................................................................................................................20 Other sites...................................................................................................................2 1 4 RELEVANT CONTEMPORARY LITERATURE...................................................24 5 SOCIOECOLOGICAL ASPECTS OF PRIMATE BEHAVIOR AND TRAUMA..30 Population Density and Resource Availability...........................................................31 Infanticide...................................................................................................................3 2 Coalitionary Killing....................................................................................................34 Primate Trauma..........................................................................................................35

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vi 6 MATERIALS AND METHODS...............................................................................36 The University of Athens Sample...............................................................................36 Methods......................................................................................................................37 7 RESULTS...................................................................................................................41 Descriptive Demographics of the Univ ersity of Athens Skeletal Sample..................41 Sex and Age.........................................................................................................41 Cause of Death....................................................................................................43 Occupation...........................................................................................................43 Trauma Frequencies....................................................................................................45 Statistical Results........................................................................................................47 Diet and health............................................................................................................51 Health Care Funding...................................................................................................52 Osteoporosis and Fractures.........................................................................................57 Geography...................................................................................................................58 Population...................................................................................................................58 Comparison to Archaeological Samples.....................................................................71 8 DISCUSSION.............................................................................................................74 Summary of findings..................................................................................................74 Diet and Disease.........................................................................................................75 Substance Abuse.........................................................................................................76 Child Abuse and Other Interpersonal Violence..........................................................77 Suggestions For Further Research..............................................................................79 APPENDIX A ZOGRAFOU CEMETERY AND MAUSOLEUM, ATHENS..................................80 B SAMPLE DOCUMENTATION FORMS..................................................................83 LIST OF REFERENCES...................................................................................................91 BIOGRAPHICAL SKETCH...........................................................................................105

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vii LIST OF TABLES Table page 3-1 Summary of skeletal an alyses of Greek and Turkis h archaeological sites published by Angel................................................................................................23 7-1 Age category frequency by sex for the UA sample...............................................42 7-2 Percentages of deaths by age cate gory for UNECE data (1997) and the UA skeletal sample.......................................................................................................42 7-3 Cause of death categories and freq uencies for the UA skeletal sample................44 7-4 Select cause of death cat egories and percentages for all Greek deaths in 1997 and the UA skeletal sample....................................................................................45 7-5 Occupation category, number and per centage for the UA skeletal sample...........45 7-6 Select employment sectors, freque ncies and percentages for Greece, 1997..........45 7-7 Trauma frequency percentages by el ement for the UA skeletal sample................46 7-8 Select socioeconomic indicators for Greece, neighbori ng Mediterranean countries and the U.S.............................................................................................49 7-9 Crime indicators, per 100,000 populati on, for Greece and the U.S., year 2000....50 7-10 Violent death rates per 100,000 population for males/females, Greece and the U.S., year 1997.......................................................................................................50 7-11 Total population increase s for Greece and greater Athens for select decades.......59 7-12 The 1997 death rates per 100,000 populati on for males/females, Greece and the United States..........................................................................................................61 7-13 Life expectancy at birth for males/females: Greece, neighboring Mediterranean countries and the United States.....................................................62 7-14 Loci used in the loglinear model and their respective skeletal elements...............67 7-15 Cross-classification of craniofacial, thoracic and appendicula r trauma in the UA sample.............................................................................................................68

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viii 7-16 Three-dimensional continge ncy table using the UA data......................................69 7-17 Research questions examined in this study and their results.................................73

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ix LIST OF FIGURES Figure page 4-1 General relationship between socioec onomic status and trauma frequency among hospital patients........................................................................................................25 7-1 Age category frequencies by sex for the UA sample...............................................42 7-2 Fractured distal left radi us (left) and normal contralate ral right radius (right), carpal view...............................................................................................................54 7-3 Fractured distal left radi us (left) and normal contralate ral radius (right), lateral view..........................................................................................................................5 5 7-4 Fractured right proximal femur................................................................................55 7-5 Orthopaedic fixation in a fr actured greater trochanter a nd neck of the right femur, anterior view.............................................................................................................56 7-6 Fractured neck and proximal diaphysis of the right femur......................................56 7-7 Craniofacial trauma caused by a motor vehicle accident in a 43-year-old male......60 7-8 Tibial fracture in a 34-year-old male........................................................................61 7-9 Age category frequencies for all Greeks, 1990 and 2000........................................63 7-10 Left femur from the UA sample with Allen’s fossa located inferior to the anterior articular surface of the femoral head........................................................................72 A-1 Primary burials maintained in Zografou Cemetery, looking northwest...................80 A-2 Extreme eastern perimeter of Zografou Cemetery...................................................80 A-3 One of two communal subterranean bone vaults on the southern perimeter of Zografou Cemetery..................................................................................................81 A-4 Close-up of a subterranean vault..............................................................................81 A-5 Interior of the Zografou Cemetery Mausoleum.......................................................82

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x Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy BIOCULTURAL VARIATION OF SKELETAL TRAUMA IN CONTEMPORARY GREEKS By Suzanne Marie Abel December 2004 Chair: Anthony B. Falsetti Major Department: Anthropology Bioarchaeological research has highlighted the impor tance of eco-geographic factors on skeletal trauma frequencies in ancient populations. Clinical research addressing trauma patterns in hospital popula tions shows that socioeconomic variables such as income, education level, minority /ethnic status, and substance abuse are significantly correlated w ith overall trauma. Research based on the behavioral mechanis m of trauma in contemporary skeletal samples is notably scarce, mainly because of the limited number of av ailable collections. As such, most of these studies are limited to fracture patterns of isolated elements or skeletal regions, and assume that injuries found in certain regi ons are predictive of overall accidental or aggressive behavior. A collection (n=121) of fully represente d and documented individuals of recent death from Athens, Greece, presented the uni que opportunity to test the influence of various demographic, ecologica l, and environmental variable s on individual trauma in a

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xi contemporary population. The sample consists of the remains of individuals donated to the Biological Laboratory at the University of Athens where the collection is currently housed for research purposes. Morphological analysis of this sample sugge sts that most of the skeletal trauma present is the result of cumulative accident al episodes. Observ ed injuries show no distinct constellations sugges ting intentional, interpersonal violence. Significant trauma clustering is seen in the thoracic vertebrae, ribs, radii, and femora of both males and females. However, these injuries are so mewhat typical in an aged, osteoporotic population such as the UA sample. Crosst abulations, ANOVA, and loglinear analyses show statistical associations between sex a nd trauma location, and between sex and cause of death category, and some degree of asso ciation among concomitant trauma locations. The UA collection seems to mirror that of contemporary Greek society at large and can be regarded as a subset of a modern society with relatively limited physical aggression. Despite geographic constraints, high unemploymen t rates, focal ized resource competition, and a surging urban population, vi olent mortality rates in Greece are among the lowest globally. Thus, contrary to so cioeconomic stress theories suggested in bioarchaeological and clinical literature, contemporary Gr eeks do not show increased trauma from assault, abuse, and other vi olent crimes due to economic and populational stressors.

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1 CHAPTER 1 INTRODUCTION The ability of the anthropologist to rec ognize and interpret skeletal trauma provides valuable information to investigators regard ing circumstances surrounding death. Victim identification is assisted th rough the analysis of individua lizing traits observed on the skeleton as well as the matching of trauma seen at a postmortem examination to antemortem medical records. The anthr opologist’s knowledge of trauma mechanism provides valuable insight into whether bony le sions are the result of violent injury or postmortem alteration. Additionally, trauma analyses bring information on intraand inter-group differences in skeletal trauma. Demogra phic trends may illuminate which biological profile is more apt to sustai n injuries within a group, thus illustrating relationships among sex, age, and trauma. Patterns can then be compared to geographically and temporally diverse groups, to determine similarities or di sparities in the cultural patterning of trauma. Within anthropology, bioarchaeological res earch has especially highlighted the importance of eco-geographical factors on trauma frequencies in ancient and historical populations. Variables include the effect of local economy (Walker 1989), resource competition (Milner et al. 1991; Stande n & Arriaza 2000), and uneven geophysical terrain (Alvrus 1999; Kilgore et al. 1997) on skeletal trauma. Clinical research based on global hospital admittance records has shown that socioeconomic variables such as income, e ducation level, minority/ethnic status, and substance abuse are significantly correlated with overall trauma frequencies (Harries

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2 1997; Cubbin et al. 2000a; 2000b; Faelker et al 2000; Lyons et al. 2000; Wagner et al. 2000; Hasselberg et al. 2001; Blakely et al. 2002 ). These same variables also influence the frequency of abuse to women, children, and elders (Grisso et al 1999; Kyriacou et al. 1999; Caetano et al. 2000; Cunradi et al. 2000). Research based on the behavioral mechanis m of trauma in contemporary skeletal samples is notably scarce, due mainly to th e limited number of available collections. As such, studies focusing specifically on trauma ar e limited to fracture patterns of isolated elements such as the forearm (Mensforth et al. 1987; Mensforth & Latimer 1989) or cranium (Walker 1997). By focusing on specifi c anatomical elements or regions of the skeleton, researchers assume that injuries found in certain regions are predictive of overall accidental or aggressive behavior. N ovak (1999) addressed this analytical bias in a study on skeletal trauma manife stations of domestic assault versus accident in a modern British casualty unit. Novak found the coexis tence of certain injuries to be most predictive of behavior. Tandem craniofacial, thoracic, and distal upper extremity injuries were more often associated with domestic assau lt, while singular, isolated fractures to the upper and lower distal extremities were more pr edictive of accidental episodes. Thus, if preservation allows, an examination of the enti re skeleton is critical when one attempts to decipher the mechanism of trauma. A cemetery collection (n=121) of well-pres erved individuals of recent death from Athens, Greece, presents a unique opportuni ty to test the influence of various demographic and environmental variables on i ndividual trauma. The skeletal remains of these individuals are on average 95% complete, a nd thus an analytical approach to trauma may be done using the entire skel eton. Associated death cer tificates include data on sex,

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3 age at death, place of birth and cause of deat h. Also included are frequent notations on last known occupation. Greek burial customs dictate that interre d bodies are exhumed after a period of 3 years and stored in mausoleums located on the cemetery grounds, unless one has made monetary provisions for permanent burial. T hose individuals or th eir families who could not afford permanent burial sites make up the collection. Using this data set, several research objectives were addressed. First tested was the relationship between the relatively low socioeco nomic status of the average Athenian and possible increased trauma frequencies. Compared to more westernized cosmopolitan cities, the population of Athens is composed of citizens of mostly low income and low education. This skeletal co llection in particular is com posed of those less wealthy citizens who could not afford permanent grav esites in the mausoleums of the Zografou Cemetery in Athens. Low income precludes acce ss to adequate diet and health care, the evidence of which will possibly be seen in the remains as poor ly treated fractures and the osseous reaction to dietary distress. Next, the relationship between the speci fic ecogeographical characteristics of Athens was tested for possible increased trau ma frequencies. Contemporary Athens has undergone very recent urban modernizati on and population surg ing, with population levels increasing almost 50% in the last 3 decades (Greece in Figures, National Statistical Service of Greece 2003). Growth in the capital is physically constrai ned within naturally limiting geographical boundaries, compounde d by mountainous and uneven terrain. Combined with the limited tourist-based local economy, Athenians are faced with stringent focal resource competition in a confined, often treacherous space.

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4 The age bias in the collection was then te sted for possible incr eases in skeletal trauma. The advanced age of many of the i ndividuals in the colle ction should result in increased cumulative antemortem injuries. Given the low socioeconomic status of the individuals, these injuries s hould also be more frequent and noticeable due to a lifetime of suboptimal health care. The overall nature of the injury pattern was explored to decide whether it provides population-specific evidence of accidental versus intentional injury. Those demographic and environmental variables most associated wi th skeletal injury were examined, and, as much as can be tested, the extent to which re ported occupation results in trauma was also reviewed. Lastly, the contemporary Greek trauma pattern was compared to those described in the archaeological literature from Greece and neighboring Mediterranean areas.

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5 CHAPTER 2 MECHANISMS OF SKELETAL TRAUMA Before reviewing the bioarchaeological and contemporary research in skeletal trauma, it is useful to briefly examine what specific injuries suggest a certain mechanism for skeletal injury. Because of individual resistance to injury, health status, cultural allowances, or barriers to trauma, and so on, there can be no cross-cu ltural list of injury constellations suggesting specific trauma mech anism. Keeping these limitations in mind, the following discussion expl ores the macroscopic qualities of regional skeletal trauma and their possible mechanisms in both the subadult and adult skeleton. Childhood Trauma The growing skeleton has specific biological and mechanical qualities that result in fractures and patterns of hea ling unlike those seen in the adult skeleton. The more biologically active subadult metaphyses and periost ea, as well as the pa tent nature of the growth plates, are some of the features precluding children to unique fractures and healing patterns. Simple linear fractures to the cranial vau lt may result from direct blows or birth trauma. While not usually fatal on their ow n, Papaefthymiou et al (1996) report on the increasing phenomenon of “growing” skull frac tures in infants who were delivered with the assistance of vacuum extraction. The cran ial bones of the infant are thin and fragile, and aggressive pulling during delivery with a vacuum apparatus may result in a fracture that is soon infiltrated with blood and/or cerebrospinal fluid. Soon after delivery, the

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6 infant’s head begins to assume the more normal rounded shape, and the originally small fracture spreads (or grows) as the vault changes shape. Fractures to the clavicle ar e very common in children, wi th fractures to the shaft making up 85% of all clavicular injuries (Webb & Mooney 2003). The most common mechanism is a fall onto the shoulder. Clavic ular fracture may also occur as a result of birth trauma, when an infant’s upper chest is either squeezed through the narrow birth canal or the infant is assisted out of the birth canal by pulling on an arm. Trauma to any of the large growth plates located at the longitudinal margins of the long bones tends to be caused by accidental falls (Webb & Mooney 2003) or direct blows (Neer 1985). Humeral shaft fractures in chil dren less than 3 year s of age are highly correlated with child abuse, especially if the fractures are spiral (Webb & Mooney 2003). Spiral fractures are caused by torque applie d in a twisting motion to the limb as one would see with children being gr asped violently by the arm. Elbow trauma is extremely common in chil dren and accounts for up to 65% of all fractures and dislocations in children (Gr een 2003). Specifically, the supracondylar area of the distal humerus is co mmonly injured from falls on an outstretched hand with the elbow hyperextended, or by dire ct falls on a flexed elbow. Fractures to the forearm are common accide ntal injuries in children. The most common cause is a fall in or around the hom e or in sports-related activities. Approximately 80% of all forearm fractures occu r in the distal third of the radius and/or ulna, with the site of the fr acture becoming more proximal with advancing skeletal age. Just over 50% of these fractures are greenst ick, or incomplete transverse fractures (Armstrong et al. 2003).

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7 Fractures to the femoral shaft usually resu lt from high-energy impact sources such as automobile accidents or falls from great he ights, although child abuse may be a culprit. Child abuse accounts for 67% of femoral shaft fr actures in children less than 1 year of age (Nork et al. 1998). Fractures to the di stal femoral metaphysis are most commonly caused by a direct blow to the anterior or la teral aspect of the thigh or by a fall from a height (Zionts 2003). In child ren less than 1 year of age, child abuse should be considered as children this young are not fu lly ambulatory. These same forces cause injury to the adjacent physis. Fractures to the tibia and fibula are mostly transverse or oblique injuries resulting from falls, motor vehicle accidents, or sports such as skiing or soccer (Thompson & Behrens 2003). Again, as in the femur or any major long bone, child abuse may be suspected if the child is less than 1 year of age or nonambulatory. Children aged between 1 and 6 years commonly experience a toddler’s fr acture at the distal tibial shaft (Dunbar et al. 1964). The injury presents as an ob lique fracture line cro ssing the distal tibial diaphysis that terminates medially. It us ually results from innocuous activity such as tripping while walking, or fa lling from a modest height. Injuries to the foot and ankle are comm only caused by indirect forces – usually hypereversion or hyperinversion of the foot (Crawford & Al-Sayyad 2003). They may also be caused via direct violence by falls from a height or by motor vehicle accidents. Child Abuse There is much debate as to which bones or skeletal regions are the most frequently injured in known cases of child abuse. So me find the middle and proximal diaphyses of the long bones to be injured most often (Beals & Tufts 1983), while others cite the vault (Kowel-Vern et al. 1992; Lodor & Bookout 1991; Skellern et al. 2000) or ribs (Akbarnia

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8 et al. 1974). Worlock et al (1986) found different patterns for infants and toddlers: abused infants exhibited more thoracic a nd vault trauma and toddlers presented with more long-bone injuries. Spiral fractures of the long bones may result from violent twisting of a limb or from shaking an infant or child while suspe nding it by a limb (O’Neill et al. 1973). Anteroposterior compression of the thorax (holding a child by the chest and squeezing) often results in rib fractures (Kleinman et al. 1992). Acute axial loading of the head against the neck (slamming a child on a floor) may produce fractures to the first ribs. The relatively heavier head of the child acts as a compressive force, transmitting energy to the first ribs via the neck muscles (Strouse & Owi ngs 1995). Thomas et al. (1991) list spiral fractures to the long bones, especially in children younger than 1 year, and all humeral fractures other than supracondylar as the more common injuries resu lting from abuse. Walker et al. (1997) found that the presence of active or healed subperiosteal bone formation, rib fractures without major chest trauma, metaphyseal fractures, and simple linear cranial fractures were possible indica tors of child abuse in forensic cases. One commonly cited pathognomonic feature of child abuse is the presence of multiple fractures in different stages of healing (Kocher & Kasser 2000; Walker et al. 1997). However, Shaw et al. ( 1997) found that spiral fractures of the humerus in children under 3 years of age were more likely the resu lt of accidental episodes than abuse, and that neither age nor fracture pa ttern were diagnostic of abuse. Whether the fractures were isolated or in association with other injuries also did not l ead to suspicion of abuse. Indeed, Lodor & Bookout (1991) found isolated acute fractures without signs of other trauma to be the most frequent pattern in battered children.

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9 While there is no set age for a child to be most vulnerable to abuse, research has shown that it mostly occurs in younger childr en, usually less than 1 year of age (Beals & Tufts 1983; Kowel-Vern et al. 1992). An awareness of conditions producing changes in bone that mimic child abuse is useful for differential diagnoses. As stated above, Walker and colleagues (1997) noted subperiosteal lesions as possibl y indicative of abuse, although they also concede that new bone formation in the metaphysis is normal in infants of 6 to 8 months of age and could be confused with trauma. Osteogenesis im perfecta, hemophilia, leukemia, and congenital indifference to pain should always be cons idered in clinical differential diagnoses (Walker et al. 1997). Adult Trauma Beginning with the craniofaci al skeleton, focal depressed fractures limited to the outer table only are termed pond fractures be cause of their shallo w, rounded appearance (Knight 1991). Pond fractures may be accide ntal in origin, although they are often attributed to interpersonal aggression. Walker (1989) found numerous pond fractures and other nonlethal craniofacial trauma in a sa mple of prehistoric Native Americans from southern California. These cranial wounds were attributed to cultura lly mediated acts of intentional violence (nonlethal face-to-face combat) resulting from resource competition stress in the geographically circumscribed area. In addition to being a common result of in tentional blunt force aggression, facial fractures are frequent injuries from vehicular accidents when the occupant is thrown facefirst into the dashboard or windshield (Gur djian 1975). Maxillary and nasal fractures may result from punches, vehicular accidents, falls, and so on. Essentially any direction of force will fracture these delicate bones, although lateral blow s tend to be most

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10 common (Watson-Jones 1941). Lateral impact to the cheek will usually result in trauma to the zygomatic bone. More posterior lateral blows will usually fractu re the arch of the zygomatic bone. Frontal impact may result in fractures to the projec ting malar tubercle. Fractures involving the lower orbital floors may be associated with complex LeFort midfacial trauma or they may be an isolated injury called a blowout fracture. They are the result of direct force over the orbit, where hydraulic changes in the globe of the eye cause compression of the bony floor. Frontal imp act to the lower orbit may also lead to buckling of the floor. Blowout fractures result from impact with a fi st or a fist-sized object (Rogers 1992). Vertebral injuries have a number of mech anisms. Injuries to the lower cervical spine tend to occur indirectly as a result of a blow to craniu m, rapid deceleration, hyperflexion, hyperextension, axial loading, or extreme rotation of the cranium (Mirza & Anderson 2003). Excessive axia l loads to the th oracolumbar region may result in compression, wedge, or burst fractures of vert ebrae. Extreme late ral flexion, extension, and rotation of the spine may cause fractures to the lateral masses, spinous processes, and/or dislocation of adjacent vertebrae. The clavicle is a frequently fractured bone in adults. Mechanisms for injury include fall from a height, motor vehicle acci dents, sports injury, and direct blows (Ring & Jupiter 2003). Humeral fractures are relatively rare in adults, accounting for only 4-5% of all fractures (Green & Norris 2003). The most common mechanism for humeral and related shoulder injury is a direct blow to the anterior, la teral, or posterolate ral aspects of the humerus. An axial load applied to the humer us through a flexed elbow may also result in

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11 fracture. Much more common is rotator cuff tearing, although the evid ence of such a soft tissue injury in bioarchaeological settings is limited to possible myositis ossificans and/or periosteal reaction of the humerus. Fractures to the tubular b ones of the hand are very common injuries in adults, especially fractures at the necks of the metacarpals (Jupiter et al. 2003). They are frequently the result of direct impact on th e metacarpal heads with the hand in a clenched fist (boxer’s fracture). Axial loads to the radial half of the palm while the wrist is in extension (falling on the palm of the hand) may fracture the scaphoid, distal radius and radial head. Fractures to the distal radius are extrem ely common, accounting for almost 20% of all fractures seen in the emergenc y department (Cohen et al. 2003). Colles (1814) first described this injury resulti ng from a fall on an outstretched hand, where energy absorbed from the impact travels through the carpus into the distal radius. Parry fractures of the medial-distal ulna result from di rect blows to the forearm as it is raised to ward off a blow to the head. Femoral neck fractures occur mostly in individuals older than 50 years (Swiontkowski 2003). While such fractures may be caused by falls from significant heights or vehicular trauma (especially in younger individuals), low-energy falls from a standing position account for 90% of fractured femoral necks in the older cohort. Age related osteoporosis, bala nce problems from decrease d strength and agility, and neuromuscular disease make older individuals prone to falls and subs equent fractures of the femoral neck and intertrochanteric regi on. Fractures to the femoral diaphysis and distal femur result mainly from falls from heights, motor vehicle accidents, and sporting injuries (Court-Brown 2003).

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12 Injuries to the tibial plateau occur mostly as a result of direct force to the proximal tibia as in a car bumper fracture (Wats on & Schatzker 2003). Transverse tibial diaphyseal fractures may result fr om a direct blow to the shins, especially if the adjacent fibula remains intact. Spiral and transverse fractures to the tibia also commonly result from sporting accidents, especially skiing. Tr ansverse boot top fractures occur when the top of the ski boot acts as a fulcrum over whic h the tibia is broken. Spiral fractures occur when the foot is stable and the body is twis ted over the foot (Trafton 2003). Stress fractures of the tibia result from repeated lo ading, with ultimate failure from fatigue. Tibial stress fractures are mostly seen in the proximal physis of individuals (such as soldiers, dancers, and runners) who place signi ficant demands on their lower extremities. Fractures to the distal end of the tibia (pilon) are most commonly caused by a fall from a height, or by a motor vehicle accident (Bar tlett et al. 1997). Forced abduction of the pronated foot is responsible for many injuries to the medial and lateral malleoli. Usually referred to as “twisted ankles”, these injuries result from tension created by the pull of the lateral or medial ligaments when the ankle is sharply inverted or everted, as when one falls off a curb. Falls from heights or mo tor vehicle accidents account for most foot injuries (DiGiovanni et al. 2003). Interpersonal Violence In general, craniofacial trauma tends to be more indicative of interpersonal aggression. Victim identity is focused in the face, and thus aggressi on to the individual is often directed there (Galloway 1999). In addi tion to the face, Fonseka (1974) found that the thorax and ventral surfaces were areas most injured during episodes of spousal abuse. Appendicular trauma tends to be more suggest ive of accidental situations. Fractures to

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13 the wrist and ankle commonly result from fa lls, especially in uneven terrain (Wells 1964). The distinction between accident al and intentional injuries is blurred; attempts to define the behavioral mechanism behind injuri es are difficult, and s hould be pursued with caution. The distinction between accidentaland vi olent-based skeletal trauma is highly dependent on cultural influences. Attempts to determine the mechanism of trauma in skeletal remains must be made in a contex tual manner, where the examination of the entire skeleton, when possible, can lead to more accurate determination of the manner in which injuries were sustained. Although many studies have addressed the physical manifestation of aggressive versus accidental trauma, just as many have failed to adequately pr opose a set pattern for skeletal expression distinguishing between the two. While due partly to differing documentation protocols, what seems to be missing from the mass of literature is the notion that aggression is dictated mainly by cu ltural norms. Every society will have its own mode of dealing with stressors, whethe r they are of environmental or behavioral origin. The physical display of intentional violence will thus show much intercultural differentiation.

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14 CHAPTER 3 RELEVENT BIOARCHAEOLOG ICAL LITERATURE Archaeologically, evidence of traumatic injuries are seen as bony changes associated with fractures, callus development, remodeling after joint dislocations, and ossifications that occur w ithin injured muscle, tendon, and periosteum. From a behavioral perspective, it is important to distinguish among injuries suffered before death (antemortem) and those around the time of d eath (perimortem). For an injury to be considered antemortem, evidence of healing mu st be present. In antemortem skeletal injuries, fracture edges are either roun ded, have woven callus formation, or are remodeled, depending on how long the individua l lived with the injury. Perimortem injuries are distinguished from postmortem damage by the lack of healing activity, by differential coloration of fractur ed ends, and by properties of the fracture. The diagnostic features of fractures produced by blunt, shar p, or projectile forces and the principles guiding the interpretations of proximate cause are well understood by forensic anthropologists. The ultimate cause is much more difficult and requi res consideration of both intrinsic biological variab les such as age and sex, and extrinsic factors relating to the physical and sociocultural context (Walker 2001). Archaeological research has highlighted the importance of sociocultural and ecogeographic factors in trauma occurrence. Using a prehistoric Indian sample from the Channel Island area of southern California, Wa lker (1989) demonstrat ed the influence of local economy on skeletal injury. Numerous cranial wounds found were attributed to intentional violence resulting from resour ce competition stress in the geographically

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15 circumscribed area. Similar resource competition and resultant warfare are also cited as explanations for like trauma found in several other lo cations, including the late prehistoric sites in Illinois (Milner et al. 1991) and Tennessee (Smith 2003), late Woodland Michigan (Wilkinson & Van Wage nen 1993), precontact central California (Jurmain & Bellifemine 1997), and the precera mic Chinchorro population from northern Chile (Standen & Arriaza 2000). In the late Woodland Michigan site, in particular, numerous females were found with cranial frac tures. These injuri es are suggested to originate from both spousal abuse and violen ce associated with female capture during warfare. Other significant bioarchaeo logical literature has show n the absence of trauma stemming from aggressive behavior. He rshkovitz and colleagues (1995) found a very low percentage of violent trauma in a collect ion of exclusively male skeletons associated with a Byzantine monastery in Judean Desert. The authors attribute the lack of cranial trauma to isolation from the secular population, regular food supply and absence of warfare. In a late Woodland foraging gr oup from Ohio, Lovejoy & Heiple (1981) found evidence of mostly accidental traumatic episodes, with the highest frequencies found in young males and females. The lack of sex diffe rential in injuries suggests that warfare was not the cause. Additionally, Smith (1996) found no sex bias in tandem parry fractures to the ulna and cran iofacial injuries in a large sample from late archaic Tennessee. If a significant number of female s had been found with such injuries, it might suggest sex-specific abuse where blows to the head and face were deflected with raised arms.

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16 Geographic factors have been associated with elevated skeletal injuries and reported in bioarchaeological studies. The uneven physical te rrain of Nubia is suggested as the particular cause of elevated accident al appendicular fracture frequencies found at the neighboring sites of Semna South (Alvrus 1999) and Kulubnarti (K ilgore et al. 1997). Both sites are in the Batn el Hajar region just south of the Egyptian border, an area characterized by a dry and boulder-strewn landscape. Skeletal Trauma Studies Using Greek Collections Mediterranean archaeological sites, and Greek sites in pa rticular, are infamous for poor skeletal preservation. Thin-to-absent t opsoil and wildly fluctuating temperatures both result in speedy degradati on of delicate bones. However, a few collections from Greece and other neighboring Mediterranean si tes have survived these environmental challenges. J. Lawrence Angel, the late Sm ithsonian Institution phys ical anthropologist, published numerous site reports on Mediterranean skeletal ma terial from the early 1940s through the mid 1970s. His reports are of vary ing length and detail, and customary of the time, are found in the appendices of archaeological site re ports. Although Angel was primarily interested in tracing Greek soci al biology through cranial morphometrics (Angel 1944, 1946), he also attempted to docum ent traumatic and pathological lesions found on archaeological remains. Franchthi Cave In a report on the skeletal remains fr om Franchthi Cave, Angel (1969) described trauma he observed on 10 individuals from this early Mesolithic to late Neolithic site in southern Greece. One adult male in the collec tion had a “vertical scar down his right jaw ramus” and a young adult female had “injured knuckles of [the] left hand” (Angel 1969:380). Another young adult male exhibi ted healed fractures of the left 1st

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17 carpometacarpal joint and 2 healed depresse d fractures of the frontal bone above the browridge. No illustrations were provided of these injuries, nor does Angel speculate on the behavioral mechanism associated with the trauma. Catal Huyuk Angel’s (1971a) thorough work at Catal H uyuk in Turkey provides a glimpse into the early farming/proto-city lif estyle of people during the ear ly Mediterranean Neolithic. Social differentiation of trauma is evident in the frequency of s kull wounds found in the Catal Huyuk sample. Six of 22 adult male cran ia exhibit vault injuri es, while only 2 of 32 females express similar trauma. Unfortunate ly, no description of th e head injuries is presented, thus limiting any speculation on the possible cause of the trauma. The fact that 27% of males exhibit in juries compared to only 6% of females provides some possible evidence of (intramale) violence. Fractures of the clavicle, humerus, ulna, radius, and femur are also found on various i ndividuals and are suggestive of accidental trauma. Angel provides inte resting scenarios for these in juries, ranging from bull goring incidents to falls from house ladders in the dark (Angel 1971a). There is no sex bias in any of these postcranial injuries. The most noted skeletal pa thology of this sample is porotic hyperostosis, which results from anemia severe enough to cause hypertrophy of the vault diploe. Of the 143 adults, 41% display this characteristic th ickening. The location of Catal Huyuk on the inland drainage of the Konya Plain meant certain and close contact with anopholine mosquitoes, which are transmitters of thalasse mia, a Mediterranean version of malaria. In addition to anemia, stresses from hunting, warfare, and trading trips would perhaps have introduced sufficient life stresses to result in interpersonal violence.

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18 Postural indicators are found on numerous individuals in this sample and provide some indication as to how these people intera cted with their environment. Reactive areas on the femoral neck (Allen’s and Poirier’s fo ssae) are frequent. These lesions develop when the ilio-femoral ligament is pressed against the zona orbicu laris during running or descending a slope. Such le sions are found in 70% of adult males and 84% of adult females. Their frequent presence, in a ddition to the number of distal appendicular fractures, suggests interaction with rough terr ain. Squatting facets (depressions on the distal tibia and/or superior talus) are found on approximately 50% of adult tibiae and tali and suggest marked ankle flexion associated with a squatting posture and/or frequent climbing. Additionally, numerous individuals in th e collection (46% of 43 femora) have a backward direction of the lesse r trochanter. The iliopsoas ten don inserts at this area and serves as a lever to tighten flexion and rotati on of the hip. This pos terior twisting of the lesser trochanter may be another reaction to flexion and stability of the thigh necessary for frequent climbing; although Angel suggest s that the twisting developed to supply added leverage for quick turning and poising needed in dancing or animal games, as shown in frescoes of th is time period (Angel 1971a). Lerna Angel (1971b) found similar postu ral indicators in individu als from Lerna, an early Neolithic to Roman era site on the Argos Plai n of the Peloponnese peninsula. Evidence of strong hip muscle development and frequent squatting facets indicate that climbing or descending steep terrain was a common occurre nce. Evidence of possible intentional trauma is seen in fractures to the ulna, 5th metacarpal (boxer’s fracture), nasals, scapula, and vault. The overall frequency of these inju ries is low (10% of the sample) and the

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19 distribution of injuries is e qually spread between males and females. The collection is quite fragmentary, however, and tr ue frequencies may be higher. The Middle Bronze Age people of Lerna re present the start of a proto-urban tradition. The era is a cultura l spinoff from the transiti on from hunting, gathering, and settled farming to urban trade and unifica tion, and is presented by Angel as a time of relative prosperity and cultural infusion. The ge neral health of the individuals from this time period is somewhat better than it is for those from earlier occupations. Porotic hyperostosis from thalassemic malaria is seen in 26% of subadults and 16% of adults (Angel 1971b). Additionally, signs of seasona l malnutrition or severe childhood disease occurring as growth arrest lines on tooth enamel are minimal. Khirokitia Earlier, Angel (1953) examined the skelet al remains of 45 subadults and 78 adults from Khirokitia, a Neolithic farming village si te on the Mediterranean island of Cyprus. Craniofacial trauma is found on 3 of 39 adult ma le crania. Injuries are seen especially on the zygomatic, frontal, parietal and occipital bones. Ange l does not provide detailed descriptions of the injuries, nor are p hotographs provided. He suggests that the craniofacial trauma is of sharp force origi n, although the injuries could represent healed linear blunt force fractures. All cranial trauma is found exclusively on males, suggesting that the injuries are of an intentionally violent origin. Certain metric and genetic observations of this collection, such as s hort-headedness, paedomorphism, and metopism are presented as strong evidence that the Kh irokitians were an inbred and parochial population that had few contacts with othe r breeding groups. Indeed, the high infant death rate, short life span, and short adult st ature in the group may be evidence that the

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20 Khirokitian villagers had little leisure time a nd were more concerned with trying to stay alive (Angel 1953). Karatas Angel’s long-term work at the Turkish necropoli at Karatas (1966, 1968, 1970, 1976) has provided valuable information rega rding life during the ea rly to middle Bronze Age on the Anatolian plateau. It is a large sample (n=584) important for its information on the health and population changes made during the development of a proto-urban economy out of an early farming subsistence. Cranial vault injuries are found on 5 males and 1 female (over 10% of all intact crania) and suggest warfare or some other form of intentional aggression (Angel 1970). Injuries are of blunt force and sharp force mechanisms (depressed fractures and axe wounds, respectively). Fractures to the midshaft of the ulnae are seen on 4 of 50 male ulnae and 1 of 30 female ulnae. Femoral shaft fractures occurred in 1 of 122 male fe mora, and 2 of 160 female femora. Schmorl’s herniations and fatigue fractures of the 5th lumbar vertebrae are cited as common, although no percentage frequenc ies are provided (Angel 1970). Minor postcranial trauma found on the femora, tibiae, clavicles, humeri and radii occur equally between the sexes. Cephallenia In a series of 40 crania from 5 different cemeteries dating to the 12th century B.C., from the Mediterranean island of Cephallenia, Angel (1943) found that 32-47% of each subsample exhibits cranial inju ries. All injuries were found in males, with the exception of 1 female bearing a depressed fracture to the right parietal. Trauma resulting from sharp force injury was found on 5 males, with 4 of them occurring on the left side. One other male had a fractured left zygomatic bone of blunt force mechanism. The preponderance of sharp force trauma in males, in addition to the frequency of injuries on

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21 the left side of the skull, demands an ethnol ogical explanation. Angel notes that the decline of the Mycenaean civiliza tion that occurr ed during the 12th century B.C. may have resulted in physical en counters with invaders from the west. Additionally, participation in the Trojan War would explai n the frequency of vi olent trauma found at this site (Angel 1943). Other sites Other reports exist describing Greek skelet al trauma found on remains from Lerna (Wesolowsky 1973), Nichoria (Wade 1983; Bi sel 1992), Attica (Angel 1945), Corinth (Angel & Burns 1973), Diros (Papathanasiou et al. 2000) and the Athenian Agora (Little & Papadopoulos 1998). However, these reports focus on either single, unique individuals or on remains far too fragment ary or commingled to provide adequate comparative data. Poor preservation aside, a few observations may be made after reviewing Angel’s anthropological reports. The relatively hi gh frequency of fractures to the distal extremities in the majority of samples is s uggestive of consistent interaction with the rough, sloping and mountainous terrain character istic of Greece. Indeed, the prevalence of postural indicators (i.e., squatting facets, Allen’s fossae) and the degree of muscular development among the individuals supports this assumption. There is also a relatively high frequency of cranial trauma suggesti ng elevated cultural stressors such as interpersonal (intramale) aggression, interneci ne warfare, and defense of the community against warring invaders. Table 3-1 compiles Angel’s more notable sk eletal analyses of Greek and Turkish sites discussed above. When Angel gave in formation on whether in juries were found in males or females, it is indicated. It should be remembered that skeletal trauma was not the focus of Angel’s work. Thus, blank cells do not necessarily mean that injuries were

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22 absent. In many of his reports, postcranial trauma was not discusse d at all. Actual cranial and postcranial trauma occurrences are likely higher than reported, as the archaeological material Angel analy zed tended to be quite fragmentary.

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23Table 3-1. Summary of skel etal analyses of Greek and Turkish ar chaeological sites published by Angel Site Francthi Cave Catal Huyuk Lern a Khirokitia Karatas Cephallenia Publication year 1969 1971a 1971b 1953 1968, 1970 1943 Time/Cultural period Early MesolithicLate Neolithic Neolithic Middle Bronze Age Neolithic Early-Middle Bronze Age 12th cent. B.C. Total sample size 10 288 234 123 540 44 (crania) Usable sample size 10 288 234 64 534 40 Cranial trauma 2 m 6 m, 2 f 2 3 m 5 m, 1 f 8 m, 1 f Postcranial trauma Shoulder girdle 1 1 1 Sternum Vertebrae 1 Pelvis Humerus 1-2 1 Forearm/Hand 1 m, 1 f 4 2 7 Femur 4 1 m, 1 f Leg/Foot 1 1

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24 CHAPTER 4 RELEVANT CONTEMPORARY LITERATURE Contemporary clinical research has shown that socioeconomic variables such as income, education level, minor ity/ethnic status and substanc e abuse are all significantly correlated with overall trauma frequencies in hospital patien ts (Harries 1997; Cubbin et al. 2000a; 2000b; Faelker et al. 2000; Lyons et al. 2000; Wagner et al. 2000; Hasselberg et al. 2001; Blakely et al. 2002). These same variables also influence the frequency of abuse to women, children and elders (Breiting et al. 1989; Grisso et al. 1999; Kyriacou et al. 1999; Caetano et al. 2000; Cunradi et al. 2000). Figure 4-1 graphically displays the gene ral relationship between socioeconomic status and trauma frequency among hospita l patients. Deprived individuals are collectively those with low in come, low education, minority st atus, history of substance and alcohol abuse, incarceration and high unemployment rate. Conversely, affluent individuals are those with re latively higher income, higher e ducation, majority status, less substance and alcohol abuse, and higher em ployment rates. As one’s socioeconomic status improves, or becomes mo re affluent, one’s overall fr equency of trauma tends to decrease. Social researchers have also found socioeconomic status to be an important factor in the type of skeletal injury encountered. Lyons et al. (2000) addr essed the influence of annual family income on childhood trauma in their study of injuries in affluent and deprived areas of Wales. When matched fo r sex and age, children from wealthier areas

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25 had higher rates of sports-related fractures wh ile those in poorer areas had more assaultrelated injuries. In addition, poorer children had considerably higher rates of death from injury than their more affluent counterparts. Moustaki et al. (2001) noted a lower overall injury rate in Greek children as compared to this same Welsh sample. They recorded a rate one-third the frequenc y found by Lyons et al. (2000), citing the better nutrition of Greek children as the biological mechanism for this decrease; presumably the better diet of Greeks led to stronger bones and less fract ures. Greek children did, however, have twice as many cranial fractures as the Welsh sample. Variation in preventive measures (lack of safety helmet use) and geographic qualities (rocky terrain) are given as reasons for this difference. deprived affluent Socioeconomic status Figure 4-1. General relations hip between socioeconomic st atus and trauma frequency among hospital patients An enormous amount of clinical literature on skeletal trauma exists in relevant medical journals. Most reports are based on hospital admittance records. The majority of reports, however, are case studies focusing on specific regions or elements of the body, such as the craniofacial skeleton (Schultz 1967; Luce et al. 1979; Voss 1982; Brook & Wood 1983; Scherer et al. 1989; Hussain et al. 1994), upper limb (Alffram & Bauer 1962), wrist (Fleege et al. 1991), and f oot (Wenig 1990; Koch & Rahimi 1991). Trauma frequency

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26 Few clinicians have attempted a systematic approach to skeletal trauma, and those that publish such data lack a sociocultural approach in their analysis. Buhr & Cook (1959) describe fracture patterns in a samp le composed of British hospital admission records for the years 1938 through 1955. Fract ures (no other skeletal trauma were investigated) were considered only by age a nd sex of the injured. The authors found that, below age 50, fractures occurred mostly in males, but above that age there was a sharp increase of trauma to women. By the decade 70-79 years, there were four times as many women with fractures as men. In a simila r study of British hospita l records, Donaldson and colleagues (1990) reported on age and sex sp ecific fracture rates in a 3-year patient cohort in the early 1980s. The authors found an identical elderly female dominance in fracture frequencies with age-related dis ease cited as the mechanism behind most injuries. Sahlin (1990) analyzed the inciden ce of fractures according to age, curiously omitting sex as a variable. Using admittance records of a Norwegian hospital from 19851986, he found advanced age to be the most im portant variable in fracture occurrence. Harries (1997) provides an interesting report focusing on the influence of sociocultural stress and physical trauma. Usi ng an epidemiological approach, the author investigated spatially distributed phenome na (violence) and the conditions (social stresses) associated with them. A “stresso r” is defined as a condition producing some degree of social dysfunction. The stress of poverty was most influential and was accompanied by a related set of deprivations in housing and other basic necessities. Using a number of variable stressors (inc luding the number of homicide/aggravated assault incidents, large households with no male figure, unemployment, poverty levels, vacant housing units nearby, adult per capita in come and education level), Harries found

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27 clusters of specific areas with shared traits in terms of the underl ying set of stressors. Harries did not focus on specific, physical exam ples of trauma. Rather, he used a public health approach to investigate why certain ar eas in an urban setting were exhibiting high frequencies of trauma. Research based on contemporary skeletal sa mple populations is scarce, due mainly to the limited number of available collecti ons. At present, there are two large and relatively well-documented accessible collecti ons, both of which are composed mostly of American individuals who either willed thei r bodies to science or who were unclaimed hospital deaths. The Hamann-Todd Osteological Collection at the Cl eveland Museum of Natural History consists of the skeletal remains of anatomical specimens who were originally unclaimed bodies retrieved from th e nearby county morgue and city hospitals from 1893-1938 (Jones-Kern & Latimer 1996). The Robert J. Terry Anatomical Skeletal Collection curated at the National Museum of Natural History at the Smithsonian Institution consists mainly of cadaver skelet ons retrieved from the Washington University Medical School. These bodies were primarily obtained from hospital and institutional morgues in the St. Louis, Missouri area from 1920-1967 (Hunt DR, August 17, 2004, www.nmnh.si.edu/anthro/cm/terry.htm). The co llection also contains some individuals who donated their bodies to science. Although much skeletal research has been done using these two samples, studies focusing specifically on trauma are curious ly limited. Mensforth et al. (1987) and Mensforth & Latimer (1989) observed fract ure patterns of speci fic elements of individuals in the Hamann-Todd collection and compared them to the same injuries in individuals of slightly more contemporary origins. Angel (1974) included a sub-sample

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28 from the Terry Collection who had willed th eir bodies to science in his report on the comparative fracture patterns of individuals from the Neolithic to modern times. Angel specifically ignored the dissecting-room co mponent of the collection, believing that “disadvantaged people exposed to tougher genetic, nutritional, and socioeconomic forces…[were] not comparable with an cient populations” (Angel 1974:9). Angel assumed the health of the contemporary industria l city-dweller was worse than that of the archaeological sample, although a large suit e of environmental stressors no doubt affected the ancient groups as well. Lastly, Walker (1997) included a sample of crania from both the Terry and Hamann-Todd collections as part of a larger study examining the skeletal evidence for the cultu ral patterning of violence in diverse Western populations. Most of these studies focused on specific anatomical elements or regions of the skeleton. The researchers thus assume that tr auma found at various si tes is predictive of overall accidental or aggressive behavior. Walker (1997) assumes that certain cranial injuries are more predictive of intentionally violent situations than other regions and he omits the postcranial skeleton in his study. Although Mensfo rth et al. (1987) indicate they were only looking for fracture patterns in certain bones, the incl usion of the entire skeleton would have provided a more accurate picture of the behavior associated with trauma. Indeed, in a study on the skeletal tr auma manifestations of patients involved in domestic assault versus accidents in a m odern British casualty unit, Novak (1999) found the coexistence of certain injuries to be most predictive of behavior. Tandem craniofacial, thoracic and distal upper extremity injuries were more often associated with domestic assault while isolated fractures to the upper and lower distal extremities were more predictive of accidental episodes. Thus if preservation allows, an examination of

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29 the entire skeleton is necessary when one at tempts to decipher the ultimate mechanism of trauma. Selecting specific elements may ease analysis, but it pres ents an artificial isolation of elements, and therefore introduces bias.

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30 CHAPTER 5 SOCIOECOLOGICAL ASPECTS OF PR IMATE BEHAVIOR AND TRAUMA Research on primate behavior is of interest to anthropologists beca use, to the extent that non-human animals engage in pl anning, cooperation, and manipulation of individuals, relationships, and al liances, their behavior must involve features which are to some degree similar to those which charac terize human behavior (Quaitt & Reynolds 1993). Anthropologists look to our primate cous ins to discover characteristics that are shared among the humans and non-human primat e evolutionary continuum. Primate studies are also pursued to di scover characteristics that ar e distinctly human, as opposed to those that might be part of the primate heritage. Of special interest to primate socioecol ogical research is the focus on withinand between-group competition. Competition can be defined simply as when species simultaneously seek essential resources of an environment that are in limited supply, be they food, social/sexual partners or safe places to live or hide (Sussman 1999). Competition depends on the availability and distribution of resource items, the monopolization of which plays a part in structuring the natu re of social relationships between members of a primate social group (V an Schaik 1989). In order to acquire resources, it pays for an individual to invest in behavioral dispositions that increase his or her superiority. Consequently, there will be a selective pressure toward individual dispositions that ar e dominance-oriented.

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31 Population Density and Resource Availability Ecological theories on aggressi ve behavior hold resource scarcity to be the crucial determinant in human societies (Harris 1974, 1979; Ross 1985, 1986). Likewise, in cases where preferred or necessary f ood items are naturally restricted to a few places, conflict and high levels of intragroup aggression are al so observed in non-human primate groups (Nagel & Kummer 1974). Borries and colleague s (1991) found that in saturated habitats of Hanuman langurs, rates of within-group aggr ession are more elevated than they are in groups living at lower populati on densities with more abundant food supplies. Here, one would expect environmental circumstances to affect the frequency of aggressive acts. Diminished resources increase the importa nce of winning; it seems only logical, therefore, to predict an incr ease in antagonistic behaviors under such circumstances. Food shortages should result in increased comp etition and status hi erarchies representing the order of access to food. Primate research on population density and aggressive behavior among various species also reports conflicti ng results, however. In a study of chimpanzees living at the Yerkes Regional Primate Research Center, Aure li & deWaal (1997) f ound that the rate of agonistic behaviors actually occurred less fr equently under high-density conditions. This was interpreted as an inhibition strategy to reduce opportunities for conflict when interindividual distances were reduced. This strategy was effective only in the short run, however, as anxiety levels were simultaneou sly elevated, suggesting increased social tension under high population density conditions When free-ranging rhesus monkeys in Cayo Santiago were faced with a temporar y food shortage, the frequency of fights decreased significantly while the frequency of grooming, play and mating also decreased. The animals became socially lethargic and spen t most of the time slowly searching for

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32 food (Loy 1970). Southwick (1976) noted that f ood shortages also resulted in decreased agonistic encounters among rhesus monkeys in Calcutta. Fighting, grooming, playing and mating behavior simultaneously declined during food shortages, suggesting tension was present even if outwardly agonistic behavior was not. Additional research suggests that primates use various affiliative mechanisms (i.e., hand-holding, altruistic beha vior) to adjust their beha vior when population density increases such that potentia lly adverse consequences of crowding and food shortages are present (Bercovitch & Lebron 1991). Social stab ility then, tends to be a more important determinant of primate aggr ession than population density. Studies on human aggression suggest that cultural features may likewise override ecological factors involved in agonistic behavior. Robarchek & Robarchek (1992) performed a comparative study on two equatorial societies in an effort to determine what factors were involved in aggres sive behavior in two eco-geogr aphically similar societies. The warlike Waorani of the Ecuadorian Amaz on live in a low population density region with plentiful resources. There are no specifi c cultural or individual values to maintain group cohesion and thus no internalized cont rols on conflict or violence. The Semai Senoi of the Malaysian rainforest experi ence higher population density with scarcer resources. Violent behavior is heavily constrained, howev er, by individual and cultural values that stress nonviolence, and by the internalized need to avoid any disruption within the kindred and band. Thus, differing cultu ral constructions be tween the two groups structured their behavior. Infanticide Darwin’s sexual selection hypothesis is believ ed to play an important role in the systematic or opportunistic killing of infant s (Darwin 1871). Sexual selection refers to

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33 the struggle between one sex fo r access to the other with th e result for the unsuccessful competitor being not death, but fewer or no o ffspring. A male increases his reproductive success by killing unrelated infants if the infa nt’s death makes the mother resume estrus sooner than she would otherwise. Unweaned infants are at th e highest risk (Hrdy et al. 1995). In addition to sexual selection, infanticid e may occur as a response to competition for territory and food resulting from envir onmental pressures (Hrdy & Hausfater 1984; Hrdy et al. 1995). Roda & Pontes (1998) documented targeted killing of unweaned infants in a group of common marmosets as a c onsequence of environmental disturbance. The population had surpassed the limited carry ing capacity of the environment, which increased competition for food, mates, and territory. Troop members had no opportunity to set up territories elsewhere and so were fo rced to compete for the scarce resources in their natal group. Infanticide may also act to reduce the number of future competitors in a group. Newton-Fisher (1999) observed two cases of male infanticide by extra-troop males in wild chimpanzees. By reducing the number of males reaching adulthood in a neighboring community, the aggr essors reduce its territorial strength, which in turn makes range expansion, recruitment of fe males, and extinction of the neighboring communities more feasible for the infantic idal males. Arcadi & Wrangham (1999) found male and female cooperation in infanticide. Females appear to gain long-term benefits by reducing resource competition or the risk of their own infa nts being attacked. Males benefit by spurring females into estrus sooner and eliminatin g future rivals. However, the fact that some of the males were related to their victims and that some did not always

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34 mate with the mother highlights how difficult it is to attribute infanticide to any one explanation. Field studies also show that increased general aggression toward females with infants occurs during boundary patrols (Watts & Mitani 2000). Chimpanzees are often seen cannibalizing the bodies of killed infa nts (Goodall 1986) suggesting that infanticide may sometimes occur as a food resource exploitation. Coalitionary Killing Intercommunity relations among certain prim ate species are predictably hostile. Muller (2002) found that coal itionary intergroup attack s are a regular feature of Kanyawara chimpanzee society. Male activit ies during border patrols for territorial defense are especially violent. Female chim panzees are found to be aggressive primarily in the context of feeding competition, alt hough levels of interpersonal aggression are rarely severe. One possible explanation is that competition for space is not as pronounced as it is at other regions, thus the benefits of female competition for high rank are less. Coalitionary attacks act to reduce the coalitionary strengt h of neighbors as well as expand territories. Other references cite tolerant and aff iliative aspects of primate relationships, especially in all-male groups. Examples in clude spider monkeys (Chapman et al. 1989), squirrel monkeys (Boinski 1994; Mitche ll 1994) and chimpanzees (De Waal 1982). Primatologists have found that cooperat ion, bonding reciprocity and negotiation among primate groups seems to depend partly on th e degree of genetic re latedness (Van Hooff 2000).

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35 Primate Trauma Targeted aggression results, then, from an amalgamation of adaptive, ecological, social, and physiological mechanisms. E nvironmental fluctuations influence the regularity of food patches and in turn affect the social and physical well being of primate troops (Roda & Pontes 1998; Saito et al. 1998 ). The introduction of stepparents or sudden group movement may spur stress among troop members resulting in “social pathology” (Snowdon & Pickhard 1999). Aggres sive behavior may result from attempts at population control (Digby 1999) or preda tion (Goodall 1986). Researchers have found that aggressive behavi or differs among species (Boinski 1999) and within species (Saito et al. 1998), the latte r suggesting that pers onality differences of troop members may reflect an individual’s own e xperiences more so than thei r genetic bac kground (Clarke & Boinski 1995). Severe wounding or death from infanticide and generalized aggr ession are frequent occurrences in most primate species. Va rious intraspecific social, physical, and ecological processes influence injury cause d by aggressive and accidental behavior. Traumatic, healed fractures in primates occur in significant frequencies and may reflect patterns of primate aggressive be havior as well as physical adaptations to environmental settings and locomotor differences. There may be different intraspecific “cultural” norms existing that regulate aggre ssive behavior. Indi vidual personality differences and the influences of life histories may also direct intraspe cific injury rates. Species may also be prone to sustain inju ries because of the dangers of different environmental settings (terrain, climate, pred ators). Such wide variances in fracture frequencies may also be the result of di ffering documentation protocols with varying ideas of what constitutes trauma. Most likely, all these factors come into play.

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36 CHAPTER 6 MATERIALS AND METHODS The following discussion describes in more detail the Greek sample used to address the research objectives introduced earlier. Documentation prot ocols and statistics used in this study are also provided. The University of Athens Sample The University of Athens (UA) skeletal sa mple is composed entirely of individuals from an ossuary located in the eastern Athe nian suburb of Zografou. They are the result of recent exhumations within the last 5 y ears from a cemetery on the same grounds. The remains have been donated to the Univers ity of Athens, Department of Human and Animal Physiology for research purposes. Greek culture follows pseudo-secondary bur ial practices. Unembalmed decedents are initially buried for a peri od of three years to allow for complete skeletonization, exhumed, and then finally stored (or re-buried) in individual containers in several large repositories located on the cemetery grounds. Those individuals who had not made provisions for the storage of their remains after exhumation are, after a period of time, eventually pulled out of the repositories and disposed of in large communal underground vaults (Appendix A). All the individuals in this collection have e ither been donated to the University of Athens by family members of the deceased or are individuals who were on their way to the communal bone vault (C. Eliopoulos, pers. comm.). Full and friendly cooperation exists between the ossuary car etakers and the University of Athens.

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37 Most skeletons were relatively free of soft tissue and odor on exhumation. Those individuals who required furt her cleaning were immersed in a weak solution of warm sodium perborate trihydrate for a period of 2-3 days in order to extract additional fat from the bone. After cleaning, the bones were ai r-dried under a protective hood, labeled, and then stored in archival boxes in the biologi cal laboratory at the University of Athens. Currently, 171 individuals are in the Greek collection, with additional remains received periodically from the Zografou ossu ary. The age at death, place of birth and death, occupation, and cause of death ar e mostly known. A few caveats must be presented explaining the quality of the data. While sex, age and places of birth and death are established forthright, other variables are somewhat questionable. Cause of death as listed on the death certificate is described interchangeably as either the primary or secondary cause. Thus, an individual ma y exhibit obvious evidence of a long-term systemic disease such as cancer, but the death certificate will cite the cause of death as ‘acute respiratory failure’. Additionally, the last known occupation provided by the death certificate is just that. In what aspect th e individual was or was not employed preceding the last known occupation is not known. Many of the individuals in this collection are of advanced aged and are listed as pensioners rendering the occupa tion variable unusable for those individuals. Methods Individuals from the sample were examined for gross antemortem and perimortem skeletal injuries. For an injury to be consid ered antemortem, evidence of healing must be present. In antemortem skeletal injuries, fracture edges are eith er rounded, have woven callus formation or are remodeled, depending on how long the indivi dual lived with the injury. Perimortem injuries are distinguish ed from postmortem damage by the lack of

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38 healing activity, differential colo ration of fractured ends and properties of the fracture. Both sexes and all ages are included in this study. In addition to fractures, skeletal evidence of soft tissue trauma (i.e., muscle and ligament injuries) was recorded. No destructive procedures were undertaken. The first data collection on a subsample (n=31) of the cemetery collection at the University of Athens during the month of Oc tober 2001 served as a pilot study. For this trip as well as the subsequent trip in September-October 2002, a thorough and efficient recording protocol was devel oped. Protocols suggested by Lovell (1997) and Buikstra & Ubelaker (1994) provided the bases for the documentation procedure. Data recording included separate forms for inventory, mor phological and metric assessments of sex, age and pathology. The inventory forms recorded data on individual element preservation by region and side. The pathology forms includ ed detailed information on fracture type, shape and sequelae. The length of the a fflicted element, as well as the apposition, rotation, and angulation at the fr acture site were recorded. Observations were also made for evidence of dislocations, amputations, arth ritis (as possible evidence for joint injury) and skeletal evidence of antemortem soft tissu e trauma. Sample data collection forms are located in Appendix B. Although data on the sex, age, and an cestry for the Greek individuals were already known from associated death certifi cates, confirmation of the biological profile data was accomplished via mor phological and metric assessme nts of diagnostic skeletal features, the most accurate of which are found on the pelvis and cranium. For the pelvis, Phenice’s (1969) technique for adult sex de termination on the pubic region was used. This method includes examination of the vent ral arc, subpubic concav ity and ischiopubic

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39 ramus. Additionally, the morphology of the grea ter sciatic notch and preauricular sulcus were considered. On the cranium, developm ent of the nuchal cres t, mastoid processes and supraorbital margins were furt her diagnostic indicators for sex. Subadult sex determination is notoriously difficult due to the lack of sexually dimorphic skeletal features, which are unde r hormonal control and thus do not appear until puberty. Although features of the auricular surface (Weav er 1980; Mittler & Sheridan 1992) and greater sciatic no tch (Boucher 1957; Weaver 1980; Schutkowski 1993) are suggested as dimorphic in subadults, none of these methods is highly accurate. Thus, morphological confirmation of sex dete rmination on subadults was not attempted. Adult age indicators were confirmed mainly from pelvic features. The morphology of the pubic symphysis according to the Suchey-Brooks scoring system (Suchey & Katz 1986; Brooks & Suchey 1990) provided the most accurate age ranges. The appearance of the auricular surface of the ilium (Lovejoy et al. 1985) supplemented age determination. Interest ingly, age ranges produced using gross morphology of the sternal rib ends (Iscan et al. 1984a, 1984b, 1985) did not appear to match the pelvic indicators in this co llection, indicating the need for a popul ation-specific criteria. This problem is currently being addressed in a forthcoming thesis by Mr. Constantine Eliopoulos, MSc, in his research using this sa me collection. Lastly, the degree of cranial suture closure (Meindl & Lovejoy 1985) a nd degree of vertebral arthritis and joint degeneration (McKern & St ewart 1957) were used to confir m age in the absence of more accurate criteria as well as to support age estimation. Subadult age is determined mainly by long bone lengths, union of primary ossification centers (Stewart 1979), tooth formation (Mooree s et al. 1963a, 1963b), tooth

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40 eruption (Schour & Massler 1941; Ubelaker 1999) and epiphyseal union (Buikstra & Ubelaker 1994). Determination of ancestry is best accomplished by examination of cranial features. Morphological and metric aspects of the midfacial (par anasal) area, facial profile and vault shape have shown to be espe cially accurate for an cestral determination (Krogman 1962; Byers 2002). Overall, co ntemporary Greeks conform to the classic European standards of craniofacial mor phology. Interestingly, personal observation of the Greek sample showed frequent metopism in both males and females as well as pronounced supraorbital ridge de velopment in many females. To explore statistical rela tionships among the data, the prevalence of trauma by bone/region and the distribution of trauma patterns were tested for independence and significance for each biological and demographic category (sex, age, cause of death, last known occupation). Summaries of percentage s, means, cross-ta bulations, ANOVAs, chi square tests for independence between variab les and loglinear modeling of multivariate categorical data explored patterns in the data.

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41 CHAPTER 7 RESULTS Descriptive Demographics of the Univ ersity of Athens Skeletal Sample Sex and Age The total sample size from the University of Athens (UA) collection is 121 individuals. There are 62 (51.2%) males and 59 (48.8%) females. Ages span from 3 to 99 years. The overall mean age is 58 years. When the three subadults in the sample are omitted (3, 6 and 14 years-old), the mean age increases to 59 years. Table 7-1 displays the frequency of individuals in each age cat egory by sex. Figure 7-1 shows how age at death in this collection is skewed toward in dividuals in the middle adult to older adult years for both males and females. To compare the demography of the UA co llection with the population of Greece at large, the United Nations Economic Comm ission for Europe (UNECE) provides data for Greece for the year 1997 (Table 7-2). This year was chosen as the target year for comparison as this was when the majority of individuals in the Greek skeletal sample died. Disparities in the percentages of individuals making up each age category between the two groups do not actually indicate true population differences. Rather, the UA collection was amassed primarily to establis h new identification protocols (namely, aging and sexing techniques) for contemporary Greek s. Individuals in the collection were chosen specifically for skeletal preser vation and specific age than for any true demographic representation. Table 7-2 illust rates this bias in collection choices.

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42 Table 7-1. Age category freque ncy by sex for the UA sample Age category Male Female Total 0-14 1 2 3 15-24 1 0 1 25-34 5 3 8 35-44 8 6 14 45-54 9 14 23 55-64 17 11 28 65-74 9 11 20 75-84 9 9 18 85+ 3 3 6 Total 62 59 121 Table 7-2. Percentages of deaths by ag e category for UNECE data (1997) and the UA skeletal sample Age category UNECE* UA sample 0-14 1.0 2.5 15-24 1.0 0.8 25-34 1.3 6.6 35-44 2.0 11.6 45-54 4.1 19.0 55-64 9.3 23.1 65-74 21.8 16.5 75-84 32.0 14.9 85+ 27.4 5.0 *UNECE Statistics for Europe and No rth America, Demographic Database. Figure 7-1. Age category freque ncies by sex for the UA sample 0 5 10 15 200 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 to 84 85+Age categoryFrequenc y males females

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43 Cause of Death Causes of death as listed on associated death certificates ranged widely from common cancerand heart-rela ted illnesses to infreque nt drug overdoses and asphyxiations. To facilitate statistical anal ysis, causes of death were compiled into somewhat discrete categories (T able 7-3). Chronic diseases of the heart were overall the most frequent illnesses leading to death in the UA sample, followed by numerous forms of cancer. For comparison, the World Health Organi zation (WHO) provides data on mortality for all of Greece. Again, the year 1997 was chosen as the target year for comparison. Table 7-4 lists select cause of death categories and frequencies for the UA sample and for all Greeks who died in 1997. By and large, chronic cardiacand cancer-related illnesses are the leading causes of deat h between the two groups. Resp iratory illness was not as common as stroke in the Greek population at large in 1997; the opposit e is true for the UA sample. Renal and cerebral illnesses, in ad dition to suicide, remain the least frequent cause of death among Greeks. Occupation Associated death certificates provide information on last known occupation for nearly half of the individuals. Many in th is collection are elderl y pensioners and are included in the unknown category. Table 7-5 gra phically displays the distribution of last known occupation among the UA skeletal sample. For comparison, Table 7-6 displays employment categories and frequencies by sele ct sectors for all Gr eek citizens during the year 1997.

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44 Table 7-3. Cause of death categories and frequencies for the UA skeletal sample Cause of death category Cause of death as listed on death certificate n % Cardiac heart attack heart failure vegetative myocardis [sic] 43 35.5 Cancer generalized colon brain liver breast stomach cyst pancreatic ovarian nasal cervical buccal lymphoma 37 30.6 Respiratory pneumonia respiratory infection emphysema lung edema 11 9.1 Stroke stroke brain hemorrhage subarachnoid hemorrhage 7 5.8 Other sipshaemic [sic] shock digestive coma choking gangrene gerontiki exantlisis 6 5.0 Trauma heavy craniocerebral injury skull and brain trauma 5 4.1 Renal chronic renal deficiency TB-C of kidney 3 2.5 Cerebral degeneration of brain advanced necrosis of brain matter Huntington’s disease 3 2.5 Unknown unknown 2 1.7 Drug Overdose drug overdose 1 0.8

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45 Table 7-4. Select cause of d eath categories and percentages for all Greek deaths in 1997 and the UA skeletal sample Category All Greeks* UA sample Cardiac 14.3 35.5 Cancer 23.4 30.6 Respiratory 3.5 9.1 Stroke 18.4 5.8 Trauma 2.3 4.1 Renal 1.5 2.5 Cerebral 1.6 2.5 Suicide 0.4 1.7 *Based on 99,738 deaths. Compiled from WHO A nnual Statistics: Table 1: Numbers of deaths and death rates. Greece, 1997. Table 7-5. Occupation categor y, number and percentage fo r the UA skeletal sample Occupation n % Unknown 56 46.28 Domestic 36 29.75 Private sector 23 19.01 Military 5 4.13 Civil servant 1 0.83 Table 7-6. Select employment sectors, frequencies and percentages for Greece, 1997 Category n % Private sector 2,886,600 27.5 Civil servant 967,500 9.2 Total employed* 3,854,100 36.7 Total unemployed* 440,400 4.2 *Based on individuals 15+ years of age. Compiled from The Yearbook of Labour Statistics. International Labour Organization, Bureau of Statistics, LABORSTA, Greece, 1997. Trauma Frequencies The skeletal remains of the individuals comprising the UA sample are very well preserved. Brief burial time and careful ha ndling by cemetery caretakers result in the majority being fully represented. Injury fr equencies were first cal culated by the per bone method (number of injured elements divided by the number of elements present). Injury frequencies were also calculated by the per individual method (number of injured

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46 elements divided by the number of individuals present). Fina lly, injury frequencies were calculated by sex. See Table 7-7. Table 7-7. Trauma frequenc y percentages by element for the UA skeletal sample. Element % per bone % per individual % per male % per female Facial 12.7 12.4 21.9 1.8 Cranium 11.7 11.6 14.1 8.8 Cervical vertebrae 2.5 5.8 6.2 5.3 Thoracic vertebrae 7.3 26.4 29.7 22.8 Lumbar vertebrae 3.6 11.6 15.6 7.0 Sacrum 11.2 9.1 7.8 10.5 Left rib 5.1 26.4 26.6 26.3 Right rib 5.6 27.3 25.0 29.8 Sternum 3.1 2.5 0.0 5.3 Left clavicle 1.8 1.7 3.1 0.0 Right clavicle 1.7 1.7 3.1 0.0 Left scapula 1.7 1.7 1.6 1.8 Right scapula 2.5 2.5 3.1 1.8 Left humerus 4.2 4.1 4.7 3.5 Right humerus 5.1 5.0 4.7 5.3 Left ulna 7.8 7.4 10.9 3.5 Right ulna 5.2 5.0 4.7 5.3 Left radius 12.2 11.6 10.9 12.3 Right radius 8.5 8.3 9.4 7.0 Left carpal 2.5 4.7 0.0 Right carpal 2.0 3.3 3.1 3.5 Left metacarpal 1.1 3.3 4.7 1.8 Right metacarpal 3.3 4.7 1.8 Left carpal phalanx 0.2 0.8 1.6 0.0 Right carpal phalanx 0.0 0.0 0.0 Left pelvis 2.5 2.5 1.6 3.5 Right pelvis 4.3 4.1 4.7 3.5 Left femur 5.9 5.8 4.7 7.0 Right femur 12.0 11.6 14.1 8.8 Left patella 0.0 0.0 0.0 0.0 Right patella 3.2 1.7 0.0 3.5 Left tibia 8.4 8.3 10.9 5.3 Right tibia 3.4 3.3 3.1 3.5 Left fibula 5.1 5.0 4.7 5.3 Right fibula 1.7 1.7 3.1 0.0 Left tarsal 1.3 5.0 6.3 3.5 Right tarsal 1.1 4.1 7.8 0.0 Left metacarpal 0.8 6.6 6.3 7.0 Right metacarpal 2.5 3.1 1.8 Left pedal phalanx 1.7 3.1 0.0 Right pedal phalanx 2.5 3.1 1.8

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47 Statistical Results In order to address the re search objectives presented in Chapter 1, numerous statistical analyses were performed. Power an alysis tested for sample size adequacy. Next, each research question is addressed. Th e prevalence of trauma by bone/region and the distribution of trauma patterns were test ed for independence and significance for each biological and demographic category (sex, age, cause of death, last known occupation). Summaries of percentages, means, crosstabulations, ANOVAs, chi square tests for independence between variables and loglinear modeling of multivariate categorical data explored patterns in the data. Sample size adequacy is tested via powe r analysis. In orde r to maximize the chances of estimating a sample statistic that closely approximates the actual parameter, power analysis ensures that the sample size is adequate. The sample size for this study is based upon a statistic that is statistically significant at the 0.05 level, with a 5% confidence interval using the following form ula proposed by Krejcie & Morgan 1970: sample size = where: 2 = chi-square formula for 1 degree of freedom ( 2 = 3.841) N = population size P = population parameter of a variable (P = 0.5) C = confidenc einterval (5%) The current population size of the UA sa mple is 171. Using this equation, a statistically adequate sample size fo r this research is 188 individuals. = 118 2NP(1-P) C2(N-1) + 2P(1-P) (3.841)(171)(.5)(.5) (.05)2(170) + (3.841)(.5)(.5)

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48 Research Question 1: Does the Relatively Low Socioeconomic Status of the Average Athenian Result in Increased Trauma in the UA Sample? Compared to neighboring Balkan and Medi terranean countries, Greece appears to prosper in certain socioeconomic aspects su ch as average annual income, level of education and annual expenditure on health (Table 7-8). Ho wever, when viewed against other westernized countries with cosmopo litan and economically competitive urban centers such as the United States and It aly, the population of Greece has comparatively low socioeconomic levels. This disparity reflects Greece’s political, economic and geographic location as a crossroads between Ba lkan repression and the modern European economy. Since entering the European Union in 1981, Greece’s economy has rapidly changed from a focus on the provincial agricultural lif estyle to an increased urban service industry catering to the needs of modernization. Greece’s claim on the commercial shipping industry has grown during the last two decades to assume 9% of the global merchant fleet (U.S. Dept. of State Post Report 2003). Despite recent urban modernization, this is still a country that must import most of its food, machinery and raw materials. Greece depends heavily on tourism for na tional income. Of the 71.6% gross domestic product provided by the service sector in 2003, over 7% originated from tourism receipts alone (UNECE Trends in Europe and North America, 2003). This limited, tourist based economy is especially felt in Athens with its focal resource competition and confined, physically trea cherous environment. Additionally, unemployment in Greece has remained consiste ntly high for the last decade and at 10.2% in 2001, it was the second highest rate in the European Union (UNECE Trends in Europe and North America, 2003).

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49 Table 7-8. Select socioeconomic indicat ors for Greece, neighbor ing Mediterranean countries and the U.S. Socioeconomic indicator Greece Cyprus Turkey FYRM* Italy U.S. Average annual income per capita (USD), 2001 11,499 7,932 4,279 3,739 15,863 24,436 Tertiary education, total students per 1,000 pop., 2001 31 16 21 31 53 Total expenditure on health (% GDP), 2001 9.2 6.0 4.3 4.5 8.0 14.0 Life expectancy at birth (yrs), m/f, 2003 75.4/80.7 65.3/67.266.8/72.570.5/74.876.7/82.9 74.1/79.5 Unemployment rate, 2001 10.2 4.0 8.5 30.5 9.5 4.8 Average household size, 2000 3.0 3.1 4.6 3.9 2.6 Population density per km2, 2003 80 82 87 79 192 30 % urban, 2003 60 70 66 59 67 77 Population growth (%), 1995-2000 0.16 1.06 1.63 0.61 0.16 1.06 Number residing foreigners (thousands) and largest foreign nationality, 2001 161.1 Russian Fed. 246.7 Germany 1464.6 Morocco 30466.0 Mexico *Former Yugoslav Republic of Macedonia. Compiled from UNECE Trends in Europe and North America, The Statistical Year book of the Economic Commission for Europe, 2003. Given Greece’s marginal socioeconomic leve ls, it is surprising that crime and violent mortality rates in the country are among the lowest in the EU and also well below the United States (Tables 7-9 and 7-10). Overall homicide rates are below the EU

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50 average and suicide rates continue to be the absolute lowest for all reference countries (Ierodiakonou et al. 1998). Table 7-9. Crime indicators, per 100,000 population, for Greece and the U.S., year 2000 Greece U.S. Serious assault 69.8 323.6 Reported rapes 2.3 32.1 Robbery, violent theft 16.6 144.9 Homicides 2.8 5.5 Compiled from INTERPOL Internationa l Crime Statistics 1989-1990 and 2000, www.interpol.int/Public/Statistics/ICS and the Fifth United Nations Survey of Crime Trends and Operations of Criminal Justice Systems, 1990-1994, UNCJIN. Socioeconomic variables such as low income, low education, high unemployment rates and high population density are significantly associated with increased frequencies of assault, abuse and other violent crimes Accordingly, one should expect to see increased frequencies of skeletal trauma in a sample based on a population with low socioeconomic status. Instances of poorly se t or non-treated fractur es where individuals either could not afford adequate medical car e or it was simply not available might be found. As stated in Chapter 2, craniofacial tr auma tends to be more indicative of interpersonal aggression. Victim identity is focused in the face and thus aggression to the individual is often directed there (Galloway 1999). In addition to the face, Fonseka (1974) found that the thorax a nd ventral surfaces were areas most injured during episodes of spousal abuse. Table 7-10. Violent death rates per 1 00,000 population for males/females, Greece and the U.S., year 1997 Greece U.S. Suicide 6.2/1.0 18.7/4.4 Homicide 2.6/0.6 13.8/3.9 Compiled from WHO Annual Statis tics, Table 1: Numbers of death and death rates. Greece, 1997, and United States of America, 1997.

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51 Only twelve individuals ( 9.9%) in the UA sample display antemortem, non-motor vehicle accident trauma to the cranium, mostly found in the paranasal region. All trauma is found in males, except for one female, wh ich suggests some form of sex-specific (intramale?) aggression is taking place. Of the 11 males, 5 injuries are found on the left side and 9 are on the right. The female exhibi ts a perimortem linear fracture to the left temporal extending into the left parietal. He r cause of death is not ed generically as a ‘brain hemorrhage’ on the death certificate, so it is possible that this injury was due to a motor vehicle accident or it coul d be a fracture (contra coup? ) from blunt force trauma of unknown mechanism. She does not display any additional skeletal trauma except for a perimortem compaction-type fracture to th e distal epiphysis of the left ulna. As seen in Table 7-7, rib fr actures are frequently encountered in this sample. No significant preference for side or exact re gion on the rib can be discerned. Several individuals have multiple rib fractures in diffe rent stages of healing, which might suggest aggression. However, the lack of concomita nt craniofacial trauma, as well as the osteoporotic state of the majo rity of skeletons, suggests either accidental (fall, motor vehicle accident) or underlyi ng pathological origin s (cancer-related os teoporosis) of the fractures. No skeletal indications of overtly intenti onal violence (i.e., parry fractures or lethal sharp force/blunt force/projectile trauma) ar e found in this collecti on. Nor is there any indication of chronic physical abuse such as multiple fractures in various stages of healing outside of the above mentioned rib fractures. Diet and health Low socioeconomic status also generall y precludes access to adequate diet and health care. Evidence of poor nutrition such as chronic anemia cau sed by iron deficiency

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52 in the diet can be seen osteologically as perpendicular orientation and expansion of the trabeculae in the cranial diploe, thinni ng of the compact cranial bone (porotic hyperostosis) and thickeni ng of the orbital roof (cribra or bitalia). These lesions result from hypertrophy of the blood-forming tissues in the marrow in order to increase the production of red blood cells in response to the anemia. The increase in marrow production results in the repla cement of the outer table of compact bone with exposed diploic bone, which gives the a ppearance of raised and porou s zones of skeletal tissue usually on the cranial vault and/or orb its (Stuart-Macadam 1987). A variety of nondietary or genetic factors ma y also cause iron deficiency including thalassemia, sickle cell anemia, traumatic blood loss, parasitic infection and chronic diarrhea (StuartMacadam 1989). Only three individuals (1 male, 2 females) in the UA sample display cranial vault porotic hyperostosis, while 5 individuals (3 ma les, 2 females) have cribra orbitalia in various stages of activity and healing at death. As age and cause of death range widely among those affected, no particular pattern is discerned regarding underlying diet, behavior or disease. Health Care Funding Funding is a perpetual problem in the development and improvement of Greek medical care. National funding cuts resulted in a decrease in the to tal number of hospital units in all of Greece from 595 in 1984 to 341 in 1998 (Greece in Figures 2003, National Statistical Service of Greece). Financial roadblocks also affect research. Indeed, attempts to organize a basic trauma registry at a teaching hospital in Crete were met with both financial setbacks as well as general l ack of enthusiastic participation from overworked hospital staff (Sanidas et al. 2000). Additionally, a recent study out of a

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53 hospital in Piraeus found that an alarming 42% of all DOAs could possibly have been prevented if pre-hospital emergency medi cal care had received funding for basic technological upgrading (P apadopoulos et al. 1996). There are 201 health centers situated in Greek rural and semi-urban areas (Theodorou 2003). These facilities are admini stratively linked to large urban health centers and are mostly staffed by recent medical graduates, who are required to spend one year of service in a rural area upon graduation. Limited human and financial resources, organizational problems and a lack of clin ical experience by docto rs raises concerns about the quality of service de livered at satellite health centers. Alt hough it is not known for certain, some of the injuries found in th e UA collection may have occurred outside of greater Athens in rural areas la cking optimum health care. This collection in particular is composed of those less wealthy citizens who for the most part could not afford permanent placement in the mausoleums of the Zografou Cemetery in Athens. The following highlights trauma found on so me of the individuals. Figure 7-2 illustrates a well-heal ed fracture to the distal le ft radius in a 59-year-old female. During a fall onto an outstretched pr onated arm, the dorsal surface of the arm is placed under compression while the ventral surf ace is under tension. The tensile forces cause a transverse fracture and there is a subsequent crumbling of the posterior (and sometimes carpal) surface. These fractures tend to result most often from low energy trauma such as a fall from a standing he ight (Galloway 1999). The carpal articular surface of this individual is comminuted and the afflicted radius is 13 mm shorter than the contralateral element. There is a 5-degree dorsal angulation. No evidence of internal or external fixation (i.e., implanted hard ware, resorbed drill tunnels) is seen.

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54 Residual deformity from a poorly treated radial fracture may have subsequent effects on wrist movement due to the precise geometry of the wrist joint. Loading patterns across the wrist are affected by very mi nor changes in distal radial geometry as little as 2.5 mm of radial shorte ning significantly shifts force lo ading to the distal ulna. This disturbs the relationships and the for ces at the distal radioulnar joint, which manifests as pain and limitation in forear m rotation (Cohen et al 2003). Although the injury to this specific indivi dual healed very well without surgical intervention, it is surprising that open reduction was not pursued. Alffram & Bauer (1962) found that in olde r women, distal forearm fractures occur more often with simultaneous fractures of th e proximal end of the femur, as might be seen in falls from a standing height. Of the 12 radii with distal fractures and the 11 proximal femora with fractures in the UA sa mple, only 3 individuals have fractures to both sites. Two of the indivi duals are elderly males and the other is an elderly female. Figure 7-2. Fractured dist al left radius (left) and normal contralateral right radius (right), carpal view Figure 7-3 shows another fractured left di stal radius, this one in a 73-year-old female. There is marked dorsal angulation and 9 mm shortening of the afflicted. Again, there is no evidence of open reduction.

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55 Figure 7-3. Fractured distal le ft radius (left) and normal contralateral radius (right), lateral view Figure 7-4 shows a fractured right proximal femur in an 81-year-old male. Postoperatively, the femoral neck retains no ticeable posterior angulation with 16 mm shortening of the afflicted element. Th ere is marked resorption around the neck component of the appliance. Poor appliance placement on the diaphysis resulted in minimal investment of the cortical screws. Such placement results in a biomechanically disadvantage femur where axial loads are not fully supported during healing. (a) (b) (c) Figure 7-4. Fractured right pr oximal femur: (a) posterior, (b) posterior-lat eral close-up of appliance and (c) posterior closeup of cortical screw in diaphysis Figure 7-5 shows a complication of flexible orthopaedic appliances (Ender nails) used to internally fix a fractured greater tr ochanter and neck of the right femur in a 78year-old male. Either excessive force duri ng insertion or inappropr iate post-operative

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56 axial loading by the patient resu lted in the nails bursting thr ough the distal anterior femur superior to the condyles. Figure 7-5. Orthopaedic fixation in a fractured greater trocha nter and neck of the right femur, anterior view Figure 7-6 shows a fractured neck and proxi mal diaphysis of the right femur in an 85-year-old male. The neck component of th e orthopaedic appliance is poorly aligned; threads are seen exposing from the cortex of the neck. The femoral head is angled anterior and marked reactive bone embedding the appliance suggests inappropriate postoperative movement of the fractured ends. (a) (b) (c) Figure 7-6. Fractured neck and proximal diaphys is of the right femur: (a) anterior, (b) posterior and (c) posterior close-up

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57 Osteoporosis and Fractures Compared with North American, Finnish and German populations, both Greek men and women have consistently lower bone mi neral density (BMD) in the decades over 40 years. In a study on BMD of the vertebrae, proximal femora and calcaneii in normal Greeks, Hadjidakis et al. (1997) found that the total bone loss between ages 20 and 70 is 29.5% for the vertebrae and 32% for the femora l neck in women, whereas the values for men are 19.5% and 29% respectively. Hip fract ures, the most dramatic complication of osteoporosis, has shown an average annual increase of 7.6% in Greeks from 1977-1992, due partly to an aging demographic (Paspati et al. 1998). While not clinically measured, the majority of individuals in the UA sample are to some degree osteoporotic. Fragile, lightweight bones are seen especi ally in the females, but also in many of the males. The advanced age of the average individual comprising the sample, as well as the high prevalence of cancer and other chronic illn esses among the group, likely contribute to frequently osteoporotic skeletons. Research Question 2: Do the Specific Geographical and Population Characteristics of Athens Result in Increased Trauma in the UA Sample? Bioarchaeological research has highlighted the importanc e of various geographical and population factors on trauma occurrence. Using a prehistoric Indi an sample from the Channel Island area of southern California, Wa lker (1989) demonstrat ed the influence of resource competition stress in the geographica lly circumscribed area on skeletal trauma frequencies. High population density and social stress broug ht on by resource competition and land scarcities are likewise bl amed for elevated craniofacial trauma found in preceramic northern Chilean coasta l communities (Standen & Arriaza 2000) and Sudanese Nubians (Alvrus 1999).

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58 Bioarchaeological studies have associat ed certain geographi cal features with elevated skeletal injuries. The uneven geophys ical terrain of Nubia is suggested as the particular cause of elevated accidental appendicular fracture frequencies found at the neighboring sites of Semna South (Alvrus 1999) and Kulubnarti (Kilgore et al. 1997). Both sites are in the Batn el Hajar region ju st south of the Egyptia n border an area characterized by a dry and boulder-strewn landscape. Geography Greece is surrounded by water on three sides: the Ionian Sea to the west, the Aegean Sea to the east and the Mediterranean Sea to the south. These adjoining seas are studded with thousands of rocky islands, of which only 200 or so are habitable. Threefourths of Greece’s terrain is rocky with little or no signifi cant topsoil (U.S. Dept. of State Post Report 2003). Athens is located in the southeastern aspect of the Attican Peninsula of the Greek mainland. It is the larges t city of the country a nd with an estimated 3,700,000 inhabitants, is home to 40% of the Greek population (U.S. Dept. of State Post Report 2003). The city itself is geographically en closed by the Parnis, Pendeli and Hymettos mountain ranges on three sides. The Gulf of Saronikos the inlet of the Aegean Sea provides the fourth border. Population The current population density of Greece is 80 individuals per km2. The city of Athens, however, has a population density of 923 individuals per km2, with 60% of the entire Greek population living in an urban se tting (UNECE Trends in Europe and North America 2003).

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59 As in many countries in Europe, the total fertility rate of Gr eece is nearly below replacement value. As a result, the rate of natural increase in Greece’s population as a whole has shown a slow growth of only about 0.06% per year, due mostly to immigrants from Albania, the Former Yugoslav Republic of Macedonia and the Russian Federation (WHO Highlights on Health in Greece 1998). Greater Athens, however, has undergone significant recent population surging, with numbers increasing almost two-fold in the last three decades due to an influx of foreign immigrants and rural Greeks into the capital pursuing economic opportunity (Table 7-11). Grow th within the country as well as in the capital are physically cons trained within naturally lim iting geographical boundaries compounded by mountainous and uneven terrain. Table 7-11. Total population increases for Greece and gr eater Athens for select decades 1971 1981 1991 2001 Greece 8,894,981 9,667,336 10,134,534 10,206,539 Athens 1,985,221 2,276,750 2,519,661 3,700,000* *2004 estimate. Compiled from Greece in Figures 2003, National Statistical Service of Greece. Despite a high unemployment rate, Greeks c ontinue to make significant purchases such as automobiles, which are unfortunately a necessity in the city due to limited mass transportation. Over one million registered ve hicles clogged the street s of Athens in 2003 (U.S. Dept. of State Post Report 2003). Given the geographic constriction of the city, this increase in road traffic has led to a subse quent increase in motor vehicle accident (MVA) fatalities. Indeed, Greece is currently the third highest for MVAs among all European Union countries (Kardara & Kondakis 1997). Four individuals in the UA collection display obvious perimortem high impact trauma caused by vehicular accidents (it is not noted on the death cer tificates whether the

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60 individual was a vehicle occupa nt or pedestrian). Skeletal trauma on these individuals includes multiple craniofacial and postcranial fractures. Figure 7-7 shows craniofacial injuries sustained by a 43-year-old male in a motor vehicle accident. Figure 7-8 shows a 34-year-old male who sustained multiple fractures from some type of (vehicular?) impact mainly to the left side of the body. The left tibia has an oblique fracture to the proximal diaphysis. The afflicted element has 26 mm shortening, 90% apposition and lateral displacement of the proximal segment. The ipsilateral fibula has a transverse fracture to the proxima l of the diaphysis, 5 mm shortening, 90% apposition and anterior displacem ent of the proximal segment. (a) (b) Figure 7-7. Craniofacial trauma caused by a motor vehicle accident in a 43-year-old male: (a) trauma to the right frontal bone including medial orbital elements and (b) close-up of the right orbital ar ea. The sclerotic callus and healed fracture in the right superior orbit la teral to the perimortem injury are evidence of a previous traumatic episode.

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61 (a) (b) Figure 7-8. Tibial fracture in a 34-year-old male : (a) left tibia, anteri or view and (b) left tibia, posterior view Despite ecogeographical constraints, high unemployment rates, focalized resources competition and a high urban population density, non -motor vehicle accidents and other violent mortality rates in Greece are among the lowest in EU countries and are also well below the United States (Table 7-12). Certai nly, skeletal injury in the UA sample seems to be overwhelmingly non-violent in origin. Table 7-12. The 1997 death rates per 100,000 popul ation for males/females, Greece and the United States Greece U.S. Males Females Males Females MVAs 34.3 10.4 21.3 10.6 Accidental falls 4.5 2.7 5.9 5.7 Suicide 6.2 1.0 18.7 4.4 Homicide 2.6 0.6 13.8 3.9 WHO Annual Statistics. Table 1: Number s of death and death rates. Greece, 1997, and United States of America, 1997. Nineteen individuals (15.7%) in the UA collection sustained trauma to the forearm and/or hand. Of these, 15 involved the distal radius, mainly taking the form of Colles’, Smith’s and radial styloid fractures. Two scaphoid fractures are also found. The

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62 locations of these injuries ar e suggestive of falls on outstre tched hands. Distribution of the injuries is spread evenly between males a nd females with an average age of 70 years. The rocky and uneven terrain of Greece, as well as the osteoporotic state of the majority of these aged individuals, possibly led to th is relatively high freque ncy of wrist injuries. Seven individuals (5.8%) have trauma to th e distal tibia, fibula or calcaneus that are suggestive of ankle-twisting injuri es or falls. Fractures to the distal diaphysis of the tibia, medial malleolus, fibular styloid process, a nd talar surface of the calcaneus are the most common ankle injuries in the collection. As with the wrist injuries the distribution of ankle injuries is spread evenly among males and females. The average age of those with ankle injuries is 69 years. Injuries in these ankle locatio ns reflects accidental trauma, probably while traversing uneven ground. Does the Age Bias of the Individuals in th e UA Sample Result in Increased Skeletal Trauma? The average life expectancy for Greek males and females in 2002 was 75.8 and 81.1 years, respectively (World Health Or ganization 2003). Greek life expectancy continues to be one of the highest in the EU community and also surpasses the average for the United States, even though Americans spend approximately 13% of their annual income of health compared to 8.4% by Greeks (see Table 7-13). Table 7-13. Life expectancy at birth for males/females: Greece, neighboring Mediterranean countries and the United States Country Life expectancy in years Males Females Greece 75.8 81.1 Italy 76.8 82.5 Cyprus 75.5 79.1 Turkey 67.9 72.2 U.S. 74.6 79.8 WHO Annex Table 1: Basic indica tors for all member states, 2002.

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63 There has been a considerable change, however, in the population structure of Greece; the number of people aged 65 year s and over has increased from 11% to 15%, while the percentage of the population aged le ss than 15 years has decreased from 25% to 17% (WHO Highlights on Health in Greece 1998). Low fertility, increased longevity and emigration of young adults from Greece for education and employment opportunities elsewhere have led to an aging of the populat ion. Figure 7-9 displays this trend in the Greek population for the decade 1990-2000. Assuming that as one ages, one is chr onologically exposed to more opportunities for traumatic episodes, the advanced age of many of the individuals in the UA collection should result in increased cumulative antemortem injuries. The Pearson r test for association between age and the total number of injuries per i ndividual resulted in a slight positive correlation ( r = .169). Thus, as age increases, so does total number of injuries. 0 500000 1000000 1500000 2000000 2500000 3000000 0-1415-2425-3435-4445-5455-6465-7475-8485+Age categoryFrequency total 1990 2000 Figure 7-9. Age category frequencies for all Greeks, 1990 and 2000. Compiled from: UNECE Trends in Europe and North Am erica. The Statistical Yearbook of the Economic Commission for Europe 2003.

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64 Biological Variables Associat ed with Skeletal Trauma Known biological variables for the UA coll ection include sex and age at death. Crosstabulations were computed for sex and general trauma location in order to determine if any significant relationship between the two variables. To facilitate analysis, all skeletal trauma was compiled into cat egories based on location. The categories include: face, head, rib/sternum, vertebrae, shoulder girdle, humerus, arm/hand, pelvic girdle, femur and leg/foot. Significance relationships exist be tween sex face ( 2 12.536, p=.00) and sex vertebrae ( 2 12.969, p=.00), with males having significantly more trauma in these two locations than fema les. No relationship was detected between sex and any other location. Chi-square tests for independence were conducted on age and the same general trauma locations described above. Nume rical age for each individual was first categorized into one of eight categories: 1 (21-30), 2 (31-40), 3 (41-50), 4 (51-60), 5 (6170), 6 (71-80), 7 (81-90) and 8 (91-100). No significance was found. Age categories were then compressed to include just three categories: 1 (21-40), 2 (41-60) and 3 (6199). Still no significant associations were found. Signifance testing was also performed to determine if males experienced more cumulative trauma than females. While there is a difference in the frequency of multiple trauma by sex (average 1.5 injuries per male, 1.9 per female), a one-way ANOVA test proved it not significant (p=.115). Population-Specific Evidence of Accide ntal Versus Intentional Injury The study of interpersonal violence as inferred from the skeleton is highly intriguing to both scholars and th e lay public. However fascina ting it is to read such sexy

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65 reports, osteologists often have difficulty dete rmining if trauma observed on an individual skeleton is the result of accidental or intentio nal mechanisms in the absence of associated weaponry. Certain types of trauma, such as parry fractures to the ulna and cranial pond fractures, are often cited as proof positive that intentionally violent encounters occurred (Wells 1964), although the true causal be havioral link suggested is unknown. Keeping these factors in mind, one can still carefully attempt to examine patterns of skeletal trauma, with the hope that causal mechanism will be illuminated. Such an analysis must take into consideration all known demographic and cultu ral variables of the collection. For example, age and sex are im portant dimensions of the modern violence pattern in that various cultura l factors may make one sex or age group more vulnerable to aggression than another. Modern assault victims show a distinctive distribution of skeletal injuries with high facial trauma rate s, especially in cases of abuse to females. The upper limb is typically the next most co mmon injury site. Novak (1999) found that tandem craniofacial and thorac ic injuries suggest aggres sion, while solo appendicular injuries suggest accidental mechanisms. To test for possible relationships between the coexistence of craniofacial, thoracic and appendicular injuries in the UA sample, loglinear modeling was applied using SPSS Advanced Models 12.0. The loglinear techni que models the means of cell counts in multi-dimensional contingency tables by desc ribing the association patterns among a set of categorical variables w ithout specifying any variable as a response (dependent) variable. It is structured to fit hierarchical linear mode ls to crosstabulations using iterative proportional-fitt ing algorithms (SPSS Adva nced Models 12.0). These techniques allow the analysis of chi-square-type data using regression-like models. They

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66 are essentially multiple linear regression models in which the classification variable and their interaction terms are the independent (predictor) variables, and the dependent variable is the natural logarithm of the frequenc y of cases in a cell of the frequency table. Using the natural log of the frequencies produces a linear model. Loglinear analysis focuses on studying asso ciations between pairs of variables rather than modeling the response on one of th em in terms of the others. The loglinear model formulae express the logs of cell e xpected frequencies in terms of dummy variables for the categorical variables and inte ractions between those variables (Agresti & Finlay 1997). Thus, all variables in the multi-dimensional contingency table used in loglinear models are response variables, rather than one a response and the others explanatory. The resulting model describes asso ciations in partial ta bles that relate, for example, two of the variables wh ile controlling for the third one. The term loglinear comes from the form of the model; the natural logarithm of cell counts is modeled as a linear function of th e effects of categorical variables and their relationships. For example, to investigat e relationships between three categorical variables X, Y and Z, the full (saturated) loglinear model is: log(m) = + X + Y + Z + XY + XZ + YZ + XYZ where: X, Y and Z represent the 1st order main effects of the independent variables XY, XZ and YZ represent the 2nd order interactive effects XYZ represents the 3rd order interactive effect of all variables X, Y and Z In the saturated model, all terms correspond to all possible main effects and interactions, and thus the model f its the data perfectly. This do es not provide any information regarding the effects of any va riable or possible interactions of variables, so one then estimates a non-saturated model containing a subs et of the parameters from the saturated

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67 model and tests the difference between that and the saturated version. Such tests are called “goodness of fit” tests, because th ey tell whether the model in question is significantly worse than the satu rated, or perfect, model. The likelihood ratio best tests the goodness of fit. If the reduced model is true, the likelihood ratio statistic has a distribution that approaches a chi-square distribution as the sample size increases. To preserve statistical power, there need to be at least 5 times the number of cases as cells in the data. For example, for a 2 x 2 x 3 contingency table, one needs to have at least 60 cases. If the required amount of cases is not met, then the sample size needs to be increased, the number of variable categorie s needs to be compressed or variables need to be eliminated. To perform loglinear modeling on the UA data, trauma locations were first organized into six skeletal loci: cranio facial, thoracic, proxi mal upper appendicular, distal upper appendicular, proximal lower appe ndicular and distal lower appendicular. Table 7-14 defines the elements of each locus. The resultant conti ngency table contained an excessive number of cells with less than the minimum of five counts, so the loci were compressed to include craniofacial, thor acic and a broader appendicular category including all elements in th e previous last four loci. Table 7-14. Loci used in th e loglinear model and their re spective skeletal elements Locus Includes Craniofacial all facial, cran ial, and mandibular elements Thoracic ribs, vertebrae, sternum Proximal upper appendicular clavicle, scapula, humerus Distal upper appendicular radius, ulna, carpals, metacarpals, phalanges Proximal lower appendicular innominates, femur Distal lower appendicular pate lla, tibia, fibula, tarsal s, metatarsals, phalanges Likelihood ratio output from loglinear testi ng of a hierarchical model compared to the saturated model indica ted no significance at the 1st, 2nd or 3rd order levels (p>.05). To

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68 test the individual 1st order effects within themselves, crosstabulations and chi-square tests for independence between the pairs cr aniofacial thoracic, craniofacial appendicular and thoracic appendicular we re conducted. All tests resulted in nonsignificant results at the .05 le vel (p=.217, .711, .104 respectively). To further test for association between the categorical variables, odds and odds ratios were computed for 2 x 2 tables cross classifying craniofacial thoracic and craniofacial appendicular loci (Table 715). Since the odds ratio treats variables symmetrically, it does not requ ire identifying a response vari able. This makes the odds ratio a natural measure when there is no obvious distinction between the variables, such as when they are both response va riables (Agresti & Finlay 1997). For individuals with cranio facial trauma, there are 2.14 (15/7) individuals with concomitant thoracic trauma for every one individual without thor acic trauma. For individuals without craniof acial trauma, the odds of ha ving thoracic trauma equal 1.16 (51/44). This means that there are 1.16 indi viduals with thoracic trauma for every one individual without thor acic trauma. For individuals with craniofacial trauma, the odds of having concomitant thoracic trauma are 1.84 (2.14/1.16) times the odds of having thoracic trauma without concomitant craniofacial trauma. Table 7-15. Cross-classificati on of craniofacial, thoracic a nd appendicular trauma in the UA sample Thoracic Appendicular Craniofacial Yes No Total Craniofacial Yes No Total Yes 15 7 22 Yes 13 9 22 No 51 44 95 No 52 43 95 For individuals with cranio facial trauma, there are 1.44 (13/9) individuals with concomitant appendicular trauma for every one individual without. For individuals

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69 without craniofacial trauma, the odds of having appendicular trauma equals 1.21. This means that there are 1.21 individuals with a ppendicular trauma for every one individual without. For individuals w ith craniofacial trauma, th e odds of having concomitant appendicular trauma are 1.19 (1.44/1.21) times the odds of having appendicular trauma without concomitant cran iofacial trauma. Put in simpler terms, these cross-classi fications indicate that individuals with craniofacial trauma also tend to sustain trauma in both the thoracic and appendicular trauma. Also, individuals are somewhat more likely to display craniofacial and thoracic trauma together than they woul d craniofacial and appendicular. Another method to determine possible patter ns in the coexiste nce of trauma at different skeletal loci is to construct a 3-dimensional conti ngency table. Table 7-16 lists the general location of skelet al trauma on all individuals in the UA collection. Each location (craniofacial, thoracic and appendicular) has one of two possible responses (yes or no). Table 7-16. Three-dimensional cont ingency table using the UA data Craniofacial Thoracic Appendicular % yes Yes No Yes Yes 9 6 60.0 No 4 3 57.1 No Yes 31 19 62.0 No 20 24 45.4 From this table, the following statements can be made: (1) for individuals with craniofacial trauma, appendicula r trauma was seen 60% of the time when thoracic trauma was also present and 57% of the time when t horacic trauma was not also present, (2) for individuals without craniofaci al trauma, appendicular trauma was seen 62% of the time when thoracic trauma was present and 45% of the time when thoracic trauma was not

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70 present, (3) for individuals without craniofacial trauma, appendicular trauma was seen 16.6% (62.0-45.4) more often when thoracic trau ma was present that when it was absent and (4) controlling for craniofacial trauma (by keeping it fixed), the percentage of appendicular trauma is higher when thoracic trauma is also present. While no obvious population-specific patter n of intentional versus aggressive injury is found, these findings further undersco re the importance of considering the entire skeleton in trauma analysis when it is availa ble. Lastly, although the UA sample does not exhibit evidence of large-scal e interpersonal aggression, the prevalence of craniofacial injury in the group is modestly high (10.7%). The fact that 12 of the 13 individuals (92.3%) are male suggests some type of cultural factor is involved w ith the frequency of trauma to this area. Occupation, Cause of Death and Sex Crosstabulations were performed to te st for possible relationships between occupation and cause of death. After all cell s with <5 were omitted (thus including only the domestic and private sector employee cat egories for occupation and unknown, cardiac and cancer categories for cause of deat h), no association wa s found between any occupation or cause of death category (p=.611). Similar crosstabulations were performed to test for possible relationships between sex and cause of death category. After all cells with <5 omitted in the cause of death categories (thus only including cardiac and cancer), significance is found between the two variables (p=.04). A possi ble association exists, the n, between sex and cause of death such that females succumb more often to cardiac illness and males succumb more often to cancer.

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71 Comparison to Archaeological Samples Trauma frequencies of the UA sample we re compared to geographically similar archaeological collections. Table 3-1 compile s skeletal analyses of various Greek and Mediterranean sites published by J. Lawrence A ngel. Several important caveats must be taken into consideration when examining this table. As previously discussed, skeletal trauma was not the focus of Angel’s work. Ra ther, he was primarily interested in tracing Greek social biology through cranial mo rphometrics (Angel 1944, 1946). He did, however, attempt to document traumatic a nd pathological conditi ons found on certain individuals. When Angel gave information on whether injuries were found in males or females, it is indicated in the table. Blank cells do not necessarily mean that injuries were absent in many of his reports, postcranial trauma was not discusse d at all. Actual cranial and postcranial trauma occurrences are likely higher than reported, as the archaeological materials Angel analy zed were usually highly fragmented. Archaeologically, fractures to the distal extremities are suggestive of consistent interaction with the rough, sloping and mount ainous terrain characte ristic of Greece. Indeed, the prevalence of postural indicators (i .e., squatting facets, Allen’s fossae) and the degree of muscular development noted am ong the individuals noted by Angel (and discussed in Chapter 3) supports this a ssumption. There is also a relatively high frequency of male cranial trauma suggesting elevated cultural stressors such as interpersonal (intramale) aggression, interneci ne warfare, and probable defense of the community against warring invaders. As with the ancient samples, numerous individuals in the contemporary UA collection display reactive areas on the femo ra called anterior cervical imprints, or Allen’s fossae (Capasso et al. 1999). This facet is found on the anterior aspect of the

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72 medical femoral neck and is due to hyperexten sion of the femur and rotation of the head in the acetabulum, usually from downhill wa lking or traversing mountainous landscapes (Figure 7-10). The zona orbicularis norm ally resists hyperextension of the femur by tightening around the femoral neck. The fossa forms where the zona bifurcates around the iliofemoral ligament. Figure 7-10. Left femur from the UA sample with Allen’s fossa located inferior to the anterior articular surface of the femoral head The prevalence of male cranial trauma over female cranial trauma is also found in the contemporary UA sample. Some type of cultural factor is causing elevated frequencies of craniofacial in jury in Greek males. Angel’s warfare proposal makes sense given the temporal and geographic nature of his ancient samples. Contemporary Greek males, however, are not in the same political position as their ancient forefathers. This sample in particular, while rather aged, is not of the correct demographic to have participated in any large-scal e political upheavals or warfare. Given the lack of other credible reasons for frequent male cranial inju ries, one is left with two possible scenarios: (1) males are simply more physically ac tive than females a nd therefore expose themselves to more opportunities for accidents or (2) males are engaging in some type of interpersonal (probably intramale) aggression.

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73 The UA collection also contains more indivi duals with wrist and ankle injuries than in Angel’s ancient samples. As individua ls from both the ancient and contemporary groups were exposed to identical geography, it makes sense that both would exhibit similar accidental trauma patterns to some degree. A likely reason why Angel’s samples show less appendicular trauma is due to the fact that he simply was not as concerned with postcranial trauma as he was obvious cran iofacial injuries and skeletal morphology. Table 7-17. Research questions examin ed in this study and their results. Question Result Does deprived socioeconomic status result in increased trauma, assault and abuse, medical care? No evidence of increased trauma, assault or abuse, but poorly treated fractures are common Do limiting geography, environmental circumscription and increased population density result in increased trauma? Increased distal appendicular injuries, but increased population density does not necessarily lead to increased overall trauma Does advanced age result in increased trauma? Yes Which biological variables are most associated with skeletal trauma? Increased facial and vertebral trauma in males Is there population-specific evidence of accidental vs. intentional injury? No. Concomitant trauma (craniofacial, thoracic and appendicular) is more likely than singular craniofacial trauma What is the relationship between occupation and cause of death? None What is the relationship between sex and cause of death? Females die more frequently from cardiac disease while males die more frequently from cancer Comparison to archaeological samples Similar male craniofacial trauma dominance and increased distal appendicular trauma

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74 CHAPTER 8 DISCUSSION Summary of findings Morphological analysis of a sample (n=121) of individuals from the University of Athens skeletal material suggests that the majo rity of skeletal trauma is the result of cumulative accidental episodes. Injuries observed show no distinct constellations suggesting intentional, interper sonal violence. Significant trauma clustering is seen in the thoracic vertebrae, ribs, radii and femora. These fracture loci are typical in an aged, osteoporotic population. Cr osstabulations, ANOVA and l oglinear analysis show associations between sex and trauma locati on, sex and cause of death category and some degree of association between c oncomitant trauma locations. No statistical relationship is found between age and trauma location. Despite what is suggested in the bioarc haeological and clinical literature, the presumed relatively low socioeconomic status of the individuals in the UA collection did not result in increased skeletal trauma. Crim e rates, violent mortal ity, and homicide and suicide rates in Greece continue to be among th e very lowest in the European Union and well below rates in the United States. Only 9.9% of the individuals sustained non-motor vehicle accident craniofacial trauma, a surpri singly low frequency given the significant social and economic stresses this population is under. Only 2.5% exhibited active or healed porotic hyperostosis and/or cribra or bitalia at death, the majority of which are likely due to chronic diseases associated with death rather than any dietary deficiencies. There is no evidence of ove rtly intentional trauma.

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75 Injuries from traversing the treacherous terrain of Greece are found in the ankle and foot area of 16% of the sample. Some 6% of the sample shows skeletal injury of the forearm and/or hands, probably the result of falls. Population surging and environmental circumscription have led to increasing trauma from motor vehicle accidents. The UA collection seems to mirror that of the overall contemporary Greek population by representing a subset of a mode rn, relatively nonviolen t society. Despite ecogeographical constraints, high unemployme nt rates, focalized resource competition and a surging urban population, violent mort ality rates in Greece are among the lowest globally. Thus, contrary to socioecono mic stress theories suggested in the bioarchaeological and clinic al literature (Harries 1997; Cubbin et al. 2000a; 2000b; Faelker 2000; Lyons et al. 2000; Wagner et al 2000; Hasselberg et al. 2001; Blakely et al. 2002), contemporary Greeks do not show increas es in trauma from assault, abuse and other violent crimes due to economic and populational stressors. Diet and Disease A Mediterranean diet high in natural oils, fish and vegetables has been shown to improve longevity, especially coronary dise ase related mortality (Trichopoulou et al. 2003). Indeed, factors that most influence a significant reduction in coronary events globally include physical activity, high levels of education and adhere nce to a traditional Mediterranean diet (Panagiota kos et al. 2002). Several emer ging lifestyle risk factors among Greeks, however, such as increasing mental depression, smoking and adopting a less healthful (fast food) diet have contributed to the st eady increase in death rates from coronary and chronic respiratory disease seen beginning in th e 1960s (Chimonas 2001; Karakatsani et al. 2003). Th e eradication of malaria, rheumatic fever, decrease in infectious diseases, improvement of medical care system and the rise of the populations’

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76 socioeconomic level during the last 5 decades in Greece have reduced all-cause mortality (Chimonas 2001). Statistically, Greece remains the country with the lowest death rates from coronary heart disease among major Eu ropean countries (Menotti et al. 1999) and with reference to total cancer mortality, Gr eeks have the lowest rates in the European Union (Black et al. 1997; Levi et al. 1999). As the UA sample is biased toward the elderly, perhaps the advanced age cohort refrained more from the newer fast f oods and kept to a healthier traditional Mediterranean diet. Even so, chronic cardiacand cancer-related illn esses are the leading causes of death among all individuals in the UA collection but are especially common in those individuals of advanced years. Regarding macroscopic skeletal eviden ce of dietary distre ss or nutrition among individuals in the UA collection, only three individuals (1 male, 2 females) display cranial vault porotic hyperostosi s, while 5 individuals (3 males, 2 females) have cribra orbitalia in various stages of activity and h ealing at death. As age and cause of death range widely among those affected, no part icular pattern is discerned regarding underlying diet, behavior or disease. Substance Abuse Greece has recently experienced an increase in drug and alcohol abuse as well as drug related illegal behavior. Kokkevi and colleagues (1993) found male gender, polydrug use, unemployment and low educati on level to be among the main factors significantly predicting criminality of drug abusers in Greece. It is important to consider the sociocultu ral context of substa nce use in the Greek population. Especially among students, s ubstance abuse has traditionally been understood differently from that of many othe r European and North American countries.

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77 Greece is a tobacco and alcohol producing country and there are no restrictions whatsoever on their sales. This, in conjuncti on with the fact that they are both socially accepted substances, explains their widespr ead use among the Greek population. While the percentage of frequent alcohol consum ers in Greece is among the highest in Europe, the majority of the youth te nd to drink only occasionally. Among students, cannabis, regular tobacco and illicit drug use have shown sharp increases during the 1990s while alcohol and unprescribed psychoactive medicines have decreased (Kokkevi et al. 2000). So, wh ile Greece is no longer among the low prevalence European countries in illicit drug us e, it still remains at much lower levels than the United States. Only one individual in the UA collec tion reportedly died of a known drug overdose. However, the advanced age of th e majority of individuals likely produces a lower than expected prevalence of drug abuse as this age cohort probably did not engage in such risk taking behaviors as much as younger individuals. Child Abuse and Other Interpersonal Violence Greece’s recent transition from a traditional to an industrialized society has resulted in cascading effects in Greek culture. The pr imary unit of change has involved the family structure, where a gradual shift is observed in organization from collectivism to individualism. The large, tr aditional extended family is be ginning to change into a more contemporary, nuclear unit with young fam ily members often leaving the home and country for economic pursuits elsewhere. Th ese changes bring with it a number of high risk factors at the individual, family, community and social levels concerning violence due to social stressors. While still relatively low compared to other European countries, Greece is just beginning to experience violent crime rates slightly above prevalence rates

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78 in the previous decades. Petridou and colle agues (2001) found that an average of 0.23% of all Greek children presen ting at hospital emergency de partments have injuries attributed to acts of violence. These inju ries are more common among migrant children who are faced with their own suite of social, cult ural and economic hurdles. As in other areas of violence, income and education seem to be the most influential factors associated with child abuse, where th e mother’s level of education mostly affects the level of prenatal/perinatal care, infant mo rtality rate and the infant’s future growth and health care (Kafatos et al. 1978). Agathonos-Georgopoulou & Browne (1997) found other high risk predictors to include a child’s poor state of hygiene upon presentation to the emergency ward, parents with mental health problems, poor relationship between parents, parents with adverse life experiences and a mother strictly disciplined by her own parents. No subadults in the UA collection bear skel etal evidence of abus e. The fact that there are only three subadults in the entire sample should be taken into consideration, however. There is also no skeletal evidence of abuse to the elderly. No population-specific data on skeletal ma nifestations of interpersonal violence among contemporary Greeks is presented here due mainly to the limited sample size upon which such standards would be drawn. A ssuming the data were adequate, a general overview of the collection shows no patterns of trauma suggesting either accidental or intentional mechanism. The na ture of this essentially non-fo rensic collection an aged population with mostly natu rally occurring deaths – pr ecludes assessment of interpersonal trauma patterns. Males in th e collection do have signi ficantly more facial trauma than females (22% and 2%, respectiv ely). Whether males are engaging more in

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79 interpersonal aggression or ar e sustaining such injuries due to more physically active interaction with the environment is unknown. Suggestions For Further Research Skeletal analyses on future remains received from the Zografou ossuary in Athens will be helpful in better answering the hypothe ses and questions proposed. It would be very helpful to amass more detailed dem ographic information including the length of time individuals actually resided in Athens (were they long term re sidents or recently transported there for medical care?). It would also be helpful to attain supporting medical documents in order to discover both the actual cause and manner of death. Any skeletal fracture details included in the hospital documentation could be used to perform postmortem analyses of fracture repair technique and outcome. If postmortem radiographic studies could be performed, fracture-healing rates could be measured. Metric evaluation of the long bone dia physis might provide information on any correlation between diaphyseal length and fractur e occurrence. Lastly, three-dimensional digitization of the crania and postcrania coul d assist with the de velopment of populationspecific identifica tion protocols.

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80 APPENDIX A ZOGRAFOU CEMETERY AND MAUSOLEUM, ATHENS Figure A-1. Primary burials maintained in Zografou Cemetery, looking northwest. Photo by the author. Figure A-2. Extreme eastern perimeter of Zogr afou Cemetery. A maintenance facility is seen in the background. Photo by the author.

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81 Figure A-3. One of two communal subterranean bone vaults on the s outhern perimeter of Zografou Cemetery. Religious icons, in cense containers a nd photographs of deceased individuals are in the fo reground. A skeletonized body still wrapped in its burial shroud can be s een within the vault. Photo by the author. Figure A-4. Close-up of a subterrane an vault. Photo by the author.

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82 Figure A-5. Interior of the Zografou Ceme tery Mausoleum. After exhumation, most individuals are secured in metal boxes and placed on shelves in this facility, where family members can come to visit. Often, the family places pictures of the deceased on the boxes. Religious icons, incense and burning candles are seen in the right foreground. Photo by the author.

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83 APPENDIX B SAMPLE DOCUMENTATION FORMS Inventory Site__________________________________Skeleton ______________________ Feature/Burial Number___________/__________ Date____________________________ Left Right Left Right Frontal ___ ___ Sphenoid ___ ___ Orbit ___ ___ Zygomatic ___ ___ Parietal ___ ___ Zygomatic Arch ___ ___ Occipital ___ ___ Maxilla ___ ___ Temporal ___ ___ Palatine ___ ___ TMJ ___ ___ Mandible ___ ___ Clavicle ___ ___ Os Coxae Scapula ___ ___ Ilium ___ ___ Body ___ ___ Ischium ___ ___ Glenoid f. ___ ___ Pubis ___ ___ Patella ___ ___ Acetabulum ___ ___ Sacrum ___ Auricular surface ___ ___ Sternum ___ Centrum Arch C1 ___ ___ T1 ___ ___ L1 ___ ___ C2 ___ ___ T2 ___ ___ L2 ___ ___ C3 ___ ___ T3 ___ ___ L3 ___ ___ C4 ___ ___ T4 ___ ___ L4 ___ ___ C5 ___ ___ T5 ___ ___ L5 ___ ___ C6 ___ ___ T6 ___ ___ C7 ___ ___ T7 ___ ___ T8 ___ ___ T9 ___ ___ T10 ___ ___ T11 ___ ___ T12 ___ ___ 1 = 75-100% present (complete) 2 = <75% present (fragmentary) 3 = absent

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84 Ribs Left Right Left Right 1 ___ ___ 7 ___ ___ 2 ___ ___ 8 ___ ___ 3 ___ ___ 9 ___ ___ 4 ___ ___ 10 ___ ___ 5 ___ ___ 11 ___ ___ 6 ___ ___ 12 ___ ___ Proximal Proximal Middle Distal Distal Epiphysis 1/3 1/3 1/3 Epiphysis Left humerus ___ ___ ___ ___ ___ Left radius ___ ___ ___ ___ ___ Left ulna ___ ___ ___ ___ ___ Left femur ___ ___ ___ ___ ___ Left tibia ___ ___ ___ ___ ___ Left fibul a ___ ___ ___ ___ ___ Right humerus ___ ___ ___ ___ ___ Right radius ___ ___ ___ ___ ___ Right ulna ___ ___ ___ ___ ___ Right femur ___ ___ ___ ___ ___ Right tibia ___ ___ ___ ___ ___ Right fibula ___ ___ ___ ___ ___ Left Right Left Right Scaphoid ___ ___ MC1 ___ ___ Lunate ___ ___ MC2 ___ ___ Triquetral ___ ___ MC3 ___ ___ Pisiform ___ ___ MC4 ___ ___ Trapezium ___ ___ MC5 ___ ___ Trapezoid ___ ___ Capitate ___ ___ Hamate ___ ___ Carpal Phalanges Left Right 1st prox ___ ___ prox ___ ___ ___ medial ___ ___ ___ 1st distal ___ ___ Carpal distal ___ ___ ___ Sesamoids (#) ___ Left Right Left Right Calcaneus ___ ___ MT1 ___ ___ Talus ___ ___ MT2 ___ ___ Cuboid ___ ___ MT3 ___ ___ Navicular ___ ___ MT4 ___ ___ Medial cuneif. ___ ___ MT5 ___ ___ Interm. cuneif. ___ ___ Lateral cuneif. ___ ___

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85 Pedal Phalanges Left Right 1st prox ___ ___ prox ___ ___ ___ medial ___ ___ ___ 1st distal ___ ___ Pedal distal ___ ___ ___ sesamoids (#) ___ Adult Sex/Age Site________________________________________Skeleton_____________________ Feature/Burial_______________________________Date_________________________ Sex Left Right Left Mid Right Ventral arc ___ ___ Nuchal crest ___ Subpubic concavity ___ ___ Mastoid process ___ ___ Ischiopubic ramus ridge ___ ___ Supraorbital margin ___ Greater sciatic notch ___ ___ Glabella ___ Preauricular sulcus ___ ___ Mandible ___ Estimated sex, pelvis ___ Esti mated sex, skull ___ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Age Pubic symphysis Left Right Left Right Suchey-Brooks Phase/Stage: ___/___ ___/___ 4th sternal rib ___ ___ Age: _______ Age: _______ Estimated age: Very young adult ( 18) ____ Young adult (20-35) ____ Middle adult (35-50) ____ Old adult (50+) ____ 1 female 2 male 3ambi g uous

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86 Subadult Measurements Site___________________________________Skeleton _________________________ Feature/Burial Number___________/________Date ____________________________ Cranial: Postcranial: L R L R Lesser wing of sphenoid Clavicle Length ___ ___ Length ___ ___ Width ___ ___ Width ___ ___ Greater wing of sphenoid Scapula Length ___ ___ Length ___ ___ Width ___ ___ Width ___ ___ Body of sphenoid Spine length ___ ___ Length ___ Ilium Width ___ Length ___ ___ Petrous Width ___ ___ Length ___ ___ Ischium Width ___ ___ Length ___ ___ Basilar occipital Width ___ ___ Length ___ Pubis Width ___ Length ___ ___ Zygomatic Humerus Length ___ ___ Length ___ ___ Width ___ ___ Width ___ ___ Maxilla Diameter ___ ___ Length ___ ___ Ulna Height ___ ___ Length ___ ___ Width ___ ___ Diameter ___ ___ Mandible Radius Body length ___ ___ Length ___ ___ Arc width ___ ___ Diameter ___ ___ Half length ___ Femur Length ___ ___ Width ___ ___ Diameter ___ ___ Tibia Length ___ ___ Diameter ___ ___ Fibula Length ___ ___ Diameter ___ ___

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87 Immature Age – Epiphyseal Union Site ___________________________________________ Skeleton _________________ Feature/Burial Number ____________/_______________ Date ____________________ Cranial Os Coxae Spheno-occipital Iliac crest ___ ___ Synchondrosis ___ Ischial tuberosity ___ ___ Occipital Femur Lateral to squama ___ Head ___ ___ Basiliar to squama ___ Greater trochanter ___ ___ Vertebrae Lesser trochanter ___ ___ Cervical ___ Distal ___ ___ Thoracic ___ Tibia Lumbar ___ Proximal ___ ___ Scapula Distal ___ ___ Coracoid ___ ___ Fibula Acromion ___ ___ Proximal ___ ___ Clavicle ___ ___ Distal ___ ___ Humerus Head ___ ___ Distal ___ ___ Medial epicondyle ___ ___ Radius Proximal ___ ___ Distal ___ ___ Age: __________________ Ulna Proximal ___ ___ Distal ___ ___ Blank = unobservable 0 = open 1 = partial union 2 = complete union

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88 Pathology Site Name/Number___________________/___________________Observer_________ Feature/Burial Number____________________/_________________Date_________________ Burial/Skeleton Number ________________ ____Sex_____________Age_________________ I. Bone___________________ Bone____________________ Bone_____________________ II. Exact__________________ Exact____________________ Exact_____________________ III. Side_______________ ____ Side___________ __________ Side ______________________ IV. Section________________ Section___________________ Section___________________ V. Aspect_________________ Aspect___________________ Aspect____________________ VI. Pathology Pathology Pathology _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ Photograph_____ Photograph_____ Photograph_____

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89 Skeletal Pathology Code Sheet I. Bone: element II. Exact: region of element III. Side: R, L, R & L IV. Section: Proximal epiphysis, intra-artic ular Middle 1/3 diaphysis Proximal epiphysis, extra-artic ular Distal 1/3 diaphysis Proximal 1/3 diaphysis Distal 2/3 diaphysis Proximal 2/3 diaphysis Dist al epiphysis, intra-articular Middle 1/3 diaphysis Midshaft V. Aspect: Superior Anterior Inferior Circumferential Medial Exocranial Lateral Endocranial Posterior VI. Pathology: Fracture Type: Complete Partial (Greenstick) Bowed (note direction) Impaction (Compression) Segmental (#) Avulsion Burst Comminuted (#) Spiral Oblique Depressed, outer table only Depressed, inner and outer tables Pathological Shape: Round Ellipsoidal Edged (sft) Projectile (entry, exit, embedded) Radiating Amputation Number of defects Length, depth of each Ante/Peri/Postmortem: Clear, Ambiguous Sequelae: Woven callus Sclerotic Healed Nonunion /pseudoarthrosis Necrosis Infection Traumatic arthritis Ankylosis Myositis ossificans Length (mm): Normal, Shortened Apposition (%) Rotation: Internal, External Angulation (degrees) Treatment Mechanism Dislocation: Traumatic, Congenital, Ambiguous

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90 Vertebrae Schmorl’s nodes: Barely discernible, Moderate, Marked Osteophytes: Barely discernibl e, Marginal, Curved spicules, Ankylosis Spina bifida: Partial, Complete Spondylolysis: Healing, Unila teral, Bilateral, Spondylolysthesis Arthritis: Lipping: Barely discernible, Sharp ridge, Spicules, Ankylosis Extent of circum ference (lipping): <1/3, 1/3-2/3, >2/3 Porosity: Pinpoint, Coalesced Extent (p orosity): <1/3, 1/3-2/3, >2/3 Eburnation: Barely discernible, Polish, Grooves Extent (p olishing): <1/3, 1/3, 2/3, >2/3 Flaring metaphysis: Barely dis cernible, Clearly discernible Craniosynostosis: Metopic, Coronal, Sagittal, Lambdoid Kyphosis Scoliosis Hydrocephaly Achondroplastic dwarf Proportional dwarfism Bone Loss: Location: Periosteal/External ta ble, Cortex, Trabeculae, Diploe, Endosteal Extent: <1/3, 1/3-2/3, >2/3 Focal/Diffuse: Nu mber of foci, Size of lesion, Circumscribed, Well-defined, Cortical thinning Bone Formation: Periostea l/Lamellar, Woven, Sclerotic Cortex: Intact, Perforated by clo aca, Spicules, Sunburst, Cauliflower Endosteal surface: Narrowed medullary cavity Extent: <1/3, 1/3-2/3, >2/3 Myositis ossificans Enthesopathy Ankylosis Button osteoma Stellate scars Sequestrum Involucrum Hyperostosis frontalis interna Torus Porotic hyperostosis: Location: Degree Activity: Active, Healed

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105 BIOGRAPHICAL SKETCH Suzanne Abel received her bachelor’s degr ee in anthropology from the University of Central Florida in 1995. Wh ile studying for her master’s degree at the University of South Carolina, she participated in the 1997 field season of the Hi erakonpolis Expedition to southern Egypt. This fieldwork resulted in her 1998 thesis, tit led “The Cranial NonMetric Traits of Hierakonpolis, Egypt” (T ed A. Rathbun, Ph.D., chair). From 1999 to 2004, she was a student at the University of Florida, where she pursued her doctoral degree in anthropology. During this time, she al so assisted in forensic casework at the C.A. Pound Human Identification Laboratory and taught courses in both the Honor’s College and the Department of Anthropology.


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Permanent Link: http://ufdc.ufl.edu/UFE0007720/00001

Material Information

Title: Biocultural Variation of Skeletal Trauma in Contemporary Greeks
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0007720:00001

Permanent Link: http://ufdc.ufl.edu/UFE0007720/00001

Material Information

Title: Biocultural Variation of Skeletal Trauma in Contemporary Greeks
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0007720:00001


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BIOCULTURAL VARIATION OF SKELETAL TRAUMA
IN CONTEMPORARY GREEKS















By

SUZANNE MARIE ABEL


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2004

































Copyright 2004

by

Suzanne Marie Abel















ACKNOWLEDGMENTS

I thank my committee members Drs. Anthony Falsetti, Michael Warren, Sue

Boinski, and Thomas Hollinger for their help in making this dissertation possible. They

each provided necessary support in one way or another, and I greatly admire their

individual talents in anthropology and anatomy.

This research was funded in part by University of Florida Foundation grants, the

William R. Maples Memorial Scholarship, and by Drs. Anthony Falsetti and Michael

Warren.

My parents Vernon Abel, Gerry Buchanan and Joyce Buchanan have given me 35

years of love, emotional support and financial help, for which I am eternally grateful.

Somehow they knew I would stick with it and finish, even when I was unsure.

I thank Dr. Sotiris Manolis for allowing me access to the skeletal collections at the

University of Athens and for his gracious hospitality. Constantine Eliopoulos provided

daily camaraderie in the lab while making the best coffee in all of Greece over a simple

lab burner. Anna Lagia also offered valuable information about the skeletal collections.

I would like to thank all the citizens of Greece I met during my time in their country.

They are truly peerless in their warmth and hospitality.

Stateside, I thank Dr. Ted Rathbun, whose infective enthusiasm about anthropology

and teaching changed my life. Anyone who has had the pleasure of meeting Ted knows

there is no one else like him. HK forever!









This dissertation could not have been done were it not for Ann Ross, Katie

Jemmott, and the rest of the CAPHIL gang. I thank them for their faithful support, the

Halloween parties and the times we sat around the lab and commiserated.

Last but certainly not least, I thank Dr. Wolf Bueschgen. He was my classmate and

fellow traveler years ago, and he continues to travel with me through life now as my

husband. What patience he possesses to put up with me.
















TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ................................................................................................. iii

LIST OF TABLES ............. ........... ...... .................. vii

LIST OF FIGURES ......... ....... .................... .......... ....... ............ ix

A B S T R A C T ............................................ ... ......... ................................... x

CHAPTER

1 IN T R O D U C T IO N ............................................................................... .............. ..

2 MECHANISMS OF SKELETAL TRAUMA............... ...................................5

C h ild h o o d T rau m a .............................................................................. .. .......... .. .. .
C h ild A b u se .......................................................... ................ 7
A du lt T rau m a ...................................... ................................................ .. 9
Interpersonal Violence.................. .. .. ............ ..... ....... 12

3 RELEVENT BIOARCHAEOLOGICAL LITERATURE .......................................14

Skeletal Traum a Studies Using Greek Collections ..................... ........................... 16
F ra n c h th i C av e ....................................................................................................... 1 6
C a ta l H u y u k ...................................................................................................1 7
Lerna ............... ..................................................... 18
K hirokitia ..............................19..............................................
K a rata s ................................................................2 0
Cephallenia ..................................................... .... 20
O th e r site s .............. .................................... ..................................................2 1

4 RELEVANT CONTEMPORARY LITERATURE .............................................. 24

5 SOCIOECOLOGICAL ASPECTS OF PRIMATE BEHAVIOR AND TRAUMA ..30

Population D ensity and Resource Availability ...........................................................31
In fa n tic id e ...................................................................................................... 3 2
Coalitionary Killing .................. 34......... ....... .........34
P rim ate T rau m a ................................................................3 5









6 M ATERIALS AND M ETHODS ........................................ ......................... 36

The University of Athens Sam ple............................................................................36
M e th o d s ..............................................................................3 7

7 R E S U L T S .............................................................................4 1

Descriptive Demographics of the University of Athens Skeletal Sample..................41
S ex an d A g e ............................................................................... 4 1
Cause of Death ................................ ........ 43
O occupation ...................... ............... .. .. .................................43
T raum a F requencies......... ........................................................................ ... ..45
Statistical Results ............... ......... .............. ................... 47
D iet an d h e alth ...................... .. ............. .. ...............................................5 1
Health Care Funding....... ...... ....... ............ ......... .............. .. ........ ..52
O osteoporosis and Fractures...................... .... ............ ..................... ............... 57
Geography ......................... ....................... 58
P o p u latio n ........... ...... ..... .. ................. .................................................5 8
Com prison to Archaeological Sam ples................................. ...................... 71

8 D IS C U S S IO N ...................... .. ............. .. ................................................7 4

Sum m ary of findings .................... .. ........... ............. .. ..... ........ .... ....... ..74
D iet an d D ise a se ................................................................................................... 7 5
Substance Abuse ................................................................................ .............................. 76
Child Abuse and Other Interpersonal Violence ..................................................77
Suggestions For Further Research................................................... .. ................ .. 79

APPENDIX

A ZOGRAFOU CEMETERY AND MAUSOLEUM, ATHENS..............................80

B SAMPLE DOCUMENTATION FORMS ................................................83

L IST O F R E F E R E N C E S ........................................................................ .....................9 1

BIOGRAPHICAL SKETCH ............................................................. ............... 105
















LIST OF TABLES


Table p

3-1 Summary of skeletal analyses of Greek and Turkish archaeological sites
published by A ngel ......................... ....... .... .. ...... ............ 23

7-1 Age category frequency by sex for the UA sample ............................................42

7-2 Percentages of deaths by age category for UNECE data (1997) and the UA
skeletal sam ple ............ ...... ....... ... ......... ...................... 42

7-3 Cause of death categories and frequencies for the UA skeletal sample ..............44

7-4 Select cause of death categories and percentages for all Greek deaths in 1997
and the U A skeletal sam ple......................................................... ............... 45

7-5 Occupation category, number and percentage for the UA skeletal sample...........45

7-6 Select employment sectors, frequencies and percentages for Greece, 1997..........45

7-7 Trauma frequency percentages by element for the UA skeletal sample................46

7-8 Select socioeconomic indicators for Greece, neighboring Mediterranean
countries and the U .S. ...................... .. .... ........................................... 49

7-9 Crime indicators, per 100,000 population, for Greece and the U.S., year 2000....50

7-10 Violent death rates per 100,000 population for males/females, Greece and the
U .S., year 1997................................................... ..................... ..... ....... 50

7-11 Total population increases for Greece and greater Athens for select decades.......59

7-12 The 1997 death rates per 100,000 population for males/females, Greece and the
U united States ..................................................................... ..........61

7-13 Life expectancy at birth for males/females: Greece, neighboring
Mediterranean countries and the United States .............................................. 62

7-14 Loci used in the loglinear model and their respective skeletal elements ..............67

7-15 Cross-classification of craniofacial, thoracic and appendicular trauma in the
U A sa m p le ....................................................... ................ 6 8









7-16 Three-dimensional contingency table using the UA data................................69

7-17 Research questions examined in this study and their results...............................73
















LIST OF FIGURES


Figure page

4-1 General relationship between socioeconomic status and trauma frequency among
hospital patients ............ ..... ...... .... ..................... 25

7-1 Age category frequencies by sex for the UA sample............... ....... ............42

7-2 Fractured distal left radius (left) and normal contralateral right radius (right),
c a rp a l v iew ...............................................................................................................5 4

7-3 Fractured distal left radius (left) and normal contralateral radius (right), lateral
v ie w ...................................... ................................... ................ 5 5

7-4 Fractured right proximal femur .................... .......................... .... ........... 55

7-5 Orthopaedic fixation in a fractured greater trochanter and neck of the right femur,
an terio r v iew ...................................... ............ ............... ................ 5 6

7-6 Fractured neck and proximal diaphysis of the right femur ................................56

7-7 Craniofacial trauma caused by a motor vehicle accident in a 43-year-old male......60

7-8 Tibial fracture in a 34-year-old m ale.................................... ........................ 61

7-9 Age category frequencies for all Greeks, 1990 and 2000 ..................................63

7-10 Left femur from the UA sample with Allen's fossa located inferior to the anterior
articular surface of the femoral head ............................ .................................... 72

A-1 Primary burials maintained in Zografou Cemetery, looking northwest ................. 80

A-2 Extreme eastern perimeter of Zografou Cemetery ................................................80

A-3 One of two communal subterranean bone vaults on the southern perimeter of
Z ografou C em etery ..................... .................. .............. .... ........... .. 1

A -4 Close-up of a subterranean vault.................................... ........................... ......... 81

A-5 Interior of the Zografou Cemetery Mausoleum ...................................................82















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

BIOCULTURAL VARIATION OF SKELETAL TRAUMA
IN CONTEMPORARY GREEKS

By

Suzanne Marie Abel

December 2004

Chair: Anthony B. Falsetti
Major Department: Anthropology

Bioarchaeological research has highlighted the importance of eco-geographic

factors on skeletal trauma frequencies in ancient populations. Clinical research

addressing trauma patterns in hospital populations shows that socioeconomic variables

such as income, education level, minority/ethnic status, and substance abuse are

significantly correlated with overall trauma.

Research based on the behavioral mechanism of trauma in contemporary skeletal

samples is notably scarce, mainly because of the limited number of available collections.

As such, most of these studies are limited to fracture patterns of isolated elements or

skeletal regions, and assume that injuries found in certain regions are predictive of overall

accidental or aggressive behavior.

A collection (n=121) of fully represented and documented individuals of recent

death from Athens, Greece, presented the unique opportunity to test the influence of

various demographic, ecological, and environmental variables on individual trauma in a









contemporary population. The sample consists of the remains of individuals donated to

the Biological Laboratory at the University of Athens where the collection is currently

housed for research purposes.

Morphological analysis of this sample suggests that most of the skeletal trauma

present is the result of cumulative accidental episodes. Observed injuries show no

distinct constellations suggesting intentional, interpersonal violence. Significant trauma

clustering is seen in the thoracic vertebrae, ribs, radii, and femora of both males and

females. However, these injuries are somewhat typical in an aged, osteoporotic

population such as the UA sample. Crosstabulations, ANOVA, and loglinear analyses

show statistical associations between sex and trauma location, and between sex and cause

of death category, and some degree of association among concomitant trauma locations.

The UA collection seems to mirror that of contemporary Greek society at large and

can be regarded as a subset of a modern society with relatively limited physical

aggression. Despite geographic constraints, high unemployment rates, focalized resource

competition, and a surging urban population, violent mortality rates in Greece are among

the lowest globally. Thus, contrary to socioeconomic stress theories suggested in

bioarchaeological and clinical literature, contemporary Greeks do not show increased

trauma from assault, abuse, and other violent crimes due to economic and populational

stressors.














CHAPTER 1
INTRODUCTION

The ability of the anthropologist to recognize and interpret skeletal trauma provides

valuable information to investigators regarding circumstances surrounding death. Victim

identification is assisted through the analysis of individualizing traits observed on the

skeleton as well as the matching of trauma seen at a postmortem examination to

antemortem medical records. The anthropologist's knowledge of trauma mechanism

provides valuable insight into whether bony lesions are the result of violent injury or

postmortem alteration.

Additionally, trauma analyses bring information on intra- and inter-group

differences in skeletal trauma. Demographic trends may illuminate which biological

profile is more apt to sustain injuries within a group, thus illustrating relationships among

sex, age, and trauma. Patterns can then be compared to geographically and temporally

diverse groups, to determine similarities or disparities in the cultural patterning of trauma.

Within anthropology, bioarchaeological research has especially highlighted the

importance of eco-geographical factors on trauma frequencies in ancient and historical

populations. Variables include the effect of local economy (Walker 1989), resource

competition (Milner et al. 1991; Standen & Arriaza 2000), and uneven geophysical

terrain (Alvrus 1999; Kilgore et al. 1997) on skeletal trauma.

Clinical research based on global hospital admittance records has shown that

socioeconomic variables such as income, education level, minority/ethnic status, and

substance abuse are significantly correlated with overall trauma frequencies (Harries









1997; Cubbin et al. 2000a; 2000b; Faelker et al. 2000; Lyons et al. 2000; Wagner et al.

2000; Hasselberg et al. 2001; Blakely et al. 2002). These same variables also influence

the frequency of abuse to women, children, and elders (Grisso et al. 1999; Kyriacou et al.

1999; Caetano et al. 2000; Cunradi et al. 2000).

Research based on the behavioral mechanism of trauma in contemporary skeletal

samples is notably scarce, due mainly to the limited number of available collections. As

such, studies focusing specifically on trauma are limited to fracture patterns of isolated

elements such as the forearm (Mensforth et al. 1987; Mensforth & Latimer 1989) or

cranium (Walker 1997). By focusing on specific anatomical elements or regions of the

skeleton, researchers assume that injuries found in certain regions are predictive of

overall accidental or aggressive behavior. Novak (1999) addressed this analytical bias in

a study on skeletal trauma manifestations of domestic assault versus accident in a modem

British casualty unit. Novak found the coexistence of certain injuries to be most

predictive of behavior. Tandem craniofacial, thoracic, and distal upper extremity injuries

were more often associated with domestic assault, while singular, isolated fractures to the

upper and lower distal extremities were more predictive of accidental episodes. Thus, if

preservation allows, an examination of the entire skeleton is critical when one attempts to

decipher the mechanism of trauma.

A cemetery collection (n=121) of well-preserved individuals of recent death from

Athens, Greece, presents a unique opportunity to test the influence of various

demographic and environmental variables on individual trauma. The skeletal remains of

these individuals are on average 95% complete, and thus an analytical approach to trauma

may be done using the entire skeleton. Associated death certificates include data on sex,









age at death, place of birth and cause of death. Also included are frequent notations on

last known occupation.

Greek burial customs dictate that interred bodies are exhumed after a period of 3

years and stored in mausoleums located on the cemetery grounds, unless one has made

monetary provisions for permanent burial. Those individuals or their families who could

not afford permanent burial sites make up the collection.

Using this data set, several research objectives were addressed. First tested was the

relationship between the relatively low socioeconomic status of the average Athenian and

possible increased trauma frequencies. Compared to more westernized cosmopolitan

cities, the population of Athens is composed of citizens of mostly low income and low

education. This skeletal collection in particular is composed of those less wealthy

citizens who could not afford permanent gravesites in the mausoleums of the Zografou

Cemetery in Athens. Low income precludes access to adequate diet and health care, the

evidence of which will possibly be seen in the remains as poorly treated fractures and the

osseous reaction to dietary distress.

Next, the relationship between the specific ecogeographical characteristics of

Athens was tested for possible increased trauma frequencies. Contemporary Athens has

undergone very recent urban modernization and population surging, with population

levels increasing almost 50% in the last 3 decades (Greece in Figures, National Statistical

Service of Greece 2003). Growth in the capital is physically constrained within naturally

limiting geographical boundaries, compounded by mountainous and uneven terrain.

Combined with the limited tourist-based local economy, Athenians are faced with

stringent focal resource competition in a confined, often treacherous space.









The age bias in the collection was then tested for possible increases in skeletal

trauma. The advanced age of many of the individuals in the collection should result in

increased cumulative antemortem injuries. Given the low socioeconomic status of the

individuals, these injuries should also be more frequent and noticeable due to a lifetime

of suboptimal health care.

The overall nature of the injury pattern was explored to decide whether it provides

population-specific evidence of accidental versus intentional injury. Those demographic

and environmental variables most associated with skeletal injury were examined, and, as

much as can be tested, the extent to which reported occupation results in trauma was also

reviewed. Lastly, the contemporary Greek trauma pattern was compared to those

described in the archaeological literature from Greece and neighboring Mediterranean

areas.














CHAPTER 2
MECHANISMS OF SKELETAL TRAUMA

Before reviewing the bioarchaeological and contemporary research in skeletal

trauma, it is useful to briefly examine what specific injuries suggest a certain mechanism

for skeletal injury. Because of individual resistance to injury, health status, cultural

allowances, or barriers to trauma, and so on, there can be no cross-cultural list of injury

constellations suggesting specific trauma mechanism. Keeping these limitations in mind,

the following discussion explores the macroscopic qualities of regional skeletal trauma

and their possible mechanisms in both the subadult and adult skeleton.

Childhood Trauma

The growing skeleton has specific biological and mechanical qualities that result in

fractures and patterns of healing unlike those seen in the adult skeleton. The more

biologically active subadult metaphyses and periostea, as well as the patent nature of the

growth plates, are some of the features precluding children to unique fractures and

healing patterns.

Simple linear fractures to the cranial vault may result from direct blows or birth

trauma. While not usually fatal on their own, Papaefthymiou et al. (1996) report on the

increasing phenomenon of "growing" skull fractures in infants who were delivered with

the assistance of vacuum extraction. The cranial bones of the infant are thin and fragile,

and aggressive pulling during delivery with a vacuum apparatus may result in a fracture

that is soon infiltrated with blood and/or cerebrospinal fluid. Soon after delivery, the









infant's head begins to assume the more normal rounded shape, and the originally small

fracture spreads (or grows) as the vault changes shape.

Fractures to the clavicle are very common in children, with fractures to the shaft

making up 85% of all clavicular injuries (Webb & Mooney 2003). The most common

mechanism is a fall onto the shoulder. Clavicular fracture may also occur as a result of

birth trauma, when an infant's upper chest is either squeezed through the narrow birth

canal or the infant is assisted out of the birth canal by pulling on an arm.

Trauma to any of the large growth plates located at the longitudinal margins of the

long bones tends to be caused by accidental falls (Webb & Mooney 2003) or direct blows

(Neer 1985). Humeral shaft fractures in children less than 3 years of age are highly

correlated with child abuse, especially if the fractures are spiral (Webb & Mooney 2003).

Spiral fractures are caused by torque applied in a twisting motion to the limb as one

would see with children being grasped violently by the arm.

Elbow trauma is extremely common in children and accounts for up to 65% of all

fractures and dislocations in children (Green 2003). Specifically, the supracondylar area

of the distal humerus is commonly injured from falls on an outstretched hand with the

elbow hyperextended, or by direct falls on a flexed elbow.

Fractures to the forearm are common accidental injuries in children. The most

common cause is a fall in or around the home or in sports-related activities.

Approximately 80% of all forearm fractures occur in the distal third of the radius and/or

ulna, with the site of the fracture becoming more proximal with advancing skeletal age.

Just over 50% of these fractures are greenstick, or incomplete transverse fractures

(Armstrong et al. 2003).









Fractures to the femoral shaft usually result from high-energy impact sources such

as automobile accidents or falls from great heights, although child abuse may be a culprit.

Child abuse accounts for 67% of femoral shaft fractures in children less than 1 year of

age (Nork et al. 1998). Fractures to the distal femoral metaphysis are most commonly

caused by a direct blow to the anterior or lateral aspect of the thigh or by a fall from a

height (Zionts 2003). In children less than 1 year of age, child abuse should be

considered as children this young are not fully ambulatory. These same forces cause

injury to the adjacent physis.

Fractures to the tibia and fibula are mostly transverse or oblique injuries resulting

from falls, motor vehicle accidents, or sports such as skiing or soccer (Thompson &

Behrens 2003). Again, as in the femur or any major long bone, child abuse may be

suspected if the child is less than 1 year of age or nonambulatory. Children aged between

1 and 6 years commonly experience a toddler's fracture at the distal tibial shaft (Dunbar

et al. 1964). The injury presents as an oblique fracture line crossing the distal tibial

diaphysis that terminates medially. It usually results from innocuous activity such as

tripping while walking, or falling from a modest height.

Injuries to the foot and ankle are commonly caused by indirect forces usually

hypereversion or hyperinversion of the foot (Crawford & Al-Sayyad 2003). They may

also be caused via direct violence by falls from a height or by motor vehicle accidents.

Child Abuse

There is much debate as to which bones or skeletal regions are the most frequently

injured in known cases of child abuse. Some find the middle and proximal diaphyses of

the long bones to be injured most often (Beals & Tufts 1983), while others cite the vault

(Kowel-Vern et al. 1992; Lodor & Bookout 1991; Skellem et al. 2000) or ribs (Akbamia









et al. 1974). Worlock et al. (1986) found different patterns for infants and toddlers:

abused infants exhibited more thoracic and vault trauma and toddlers presented with

more long-bone injuries.

Spiral fractures of the long bones may result from violent twisting of a limb or from

shaking an infant or child while suspending it by a limb (O'Neill et al. 1973).

Anteroposterior compression of the thorax (holding a child by the chest and squeezing)

often results in rib fractures (Kleinman et al. 1992). Acute axial loading of the head

against the neck (slamming a child on a floor) may produce fractures to the first ribs. The

relatively heavier head of the child acts as a compressive force, transmitting energy to the

first ribs via the neck muscles (Strouse & Owings 1995). Thomas et al. (1991) list spiral

fractures to the long bones, especially in children younger than 1 year, and all humeral

fractures other than supracondylar as the more common injuries resulting from abuse.

Walker et al. (1997) found that the presence of active or healed subperiosteal bone

formation, rib fractures without major chest trauma, metaphyseal fractures, and simple

linear cranial fractures were possible indicators of child abuse in forensic cases.

One commonly cited pathognomonic feature of child abuse is the presence of

multiple fractures in different stages of healing (Kocher & Kasser 2000; Walker et al.

1997). However, Shaw et al. (1997) found that spiral fractures of the humerus in children

under 3 years of age were more likely the result of accidental episodes than abuse, and

that neither age nor fracture pattern were diagnostic of abuse. Whether the fractures were

isolated or in association with other injuries also did not lead to suspicion of abuse.

Indeed, Lodor & Bookout (1991) found isolated acute fractures without signs of other

trauma to be the most frequent pattern in battered children.









While there is no set age for a child to be most vulnerable to abuse, research has

shown that it mostly occurs in younger children, usually less than 1 year of age (Beals &

Tufts 1983; Kowel-Vern et al. 1992).

An awareness of conditions producing changes in bone that mimic child abuse is

useful for differential diagnoses. As stated above, Walker and colleagues (1997) noted

subperiosteal lesions as possibly indicative of abuse, although they also concede that new

bone formation in the metaphysis is normal in infants of 6 to 8 months of age and could

be confused with trauma. Osteogenesis imperfecta, hemophilia, leukemia, and congenital

indifference to pain should always be considered in clinical differential diagnoses

(Walker et al. 1997).

Adult Trauma

Beginning with the craniofacial skeleton, focal depressed fractures limited to the

outer table only are termed pond fractures because of their shallow, rounded appearance

(Knight 1991). Pond fractures may be accidental in origin, although they are often

attributed to interpersonal aggression. Walker (1989) found numerous pond fractures and

other nonlethal craniofacial trauma in a sample of prehistoric Native Americans from

southern California. These cranial wounds were attributed to culturally mediated acts of

intentional violence (nonlethal face-to-face combat) resulting from resource competition

stress in the geographically circumscribed area.

In addition to being a common result of intentional blunt force aggression, facial

fractures are frequent injuries from vehicular accidents when the occupant is thrown face-

first into the dashboard or windshield (Gurdjian 1975). Maxillary and nasal fractures

may result from punches, vehicular accidents, falls, and so on. Essentially any direction

of force will fracture these delicate bones, although lateral blows tend to be most









common (Watson-Jones 1941). Lateral impact to the cheek will usually result in trauma

to the zygomatic bone. More posterior lateral blows will usually fracture the arch of the

zygomatic bone. Frontal impact may result in fractures to the projecting malar tubercle.

Fractures involving the lower orbital floors may be associated with complex LeFort

midfacial trauma or they may be an isolated injury called a blowout fracture. They are

the result of direct force over the orbit, where hydraulic changes in the globe of the eye

cause compression of the bony floor. Frontal impact to the lower orbit may also lead to

buckling of the floor. Blowout fractures result from impact with a fist or a fist-sized

object (Rogers 1992).

Vertebral injuries have a number of mechanisms. Injuries to the lower cervical

spine tend to occur indirectly as a result of a blow to cranium, rapid deceleration,

hyperflexion, hyperextension, axial loading, or extreme rotation of the cranium (Mirza &

Anderson 2003). Excessive axial loads to the thoracolumbar region may result in

compression, wedge, or burst fractures of vertebrae. Extreme lateral flexion, extension,

and rotation of the spine may cause fractures to the lateral masses, spinous processes,

and/or dislocation of adjacent vertebrae.

The clavicle is a frequently fractured bone in adults. Mechanisms for injury

include fall from a height, motor vehicle accidents, sports injury, and direct blows (Ring

& Jupiter 2003).

Humeral fractures are relatively rare in adults, accounting for only 4-5% of all

fractures (Green & Norris 2003). The most common mechanism for humeral and related

shoulder injury is a direct blow to the anterior, lateral, or posterolateral aspects of the

humerus. An axial load applied to the humerus through a flexed elbow may also result in









fracture. Much more common is rotator cuff tearing, although the evidence of such a soft

tissue injury in bioarchaeological settings is limited to possible myositis ossificans and/or

periosteal reaction of the humerus.

Fractures to the tubular bones of the hand are very common injuries in adults,

especially fractures at the necks of the metacarpals (Jupiter et al. 2003). They are

frequently the result of direct impact on the metacarpal heads with the hand in a clenched

fist (boxer's fracture). Axial loads to the radial half of the palm while the wrist is in

extension (falling on the palm of the hand) may fracture the scaphoid, distal radius and

radial head. Fractures to the distal radius are extremely common, accounting for almost

20% of all fractures seen in the emergency department (Cohen et al. 2003). Colles

(1814) first described this injury resulting from a fall on an outstretched hand, where

energy absorbed from the impact travels through the carpus into the distal radius. Parry

fractures of the medial-distal ulna result from direct blows to the forearm as it is raised to

ward off a blow to the head.

Femoral neck fractures occur mostly in individuals older than 50 years

(Swiontkowski 2003). While such fractures may be caused by falls from significant

heights or vehicular trauma (especially in younger individuals), low-energy falls from a

standing position account for 90% of fractured femoral necks in the older cohort. Age

related osteoporosis, balance problems from decreased strength and agility, and

neuromuscular disease make older individuals prone to falls and subsequent fractures of

the femoral neck and intertrochanteric region. Fractures to the femoral diaphysis and

distal femur result mainly from falls from heights, motor vehicle accidents, and sporting

injuries (Court-Brown 2003).









Injuries to the tibial plateau occur mostly as a result of direct force to the proximal

tibia as in a car bumper fracture (Watson & Schatzker 2003). Transverse tibial

diaphyseal fractures may result from a direct blow to the shins, especially if the adjacent

fibula remains intact. Spiral and transverse fractures to the tibia also commonly result

from sporting accidents, especially skiing. Transverse boot top fractures occur when the

top of the ski boot acts as a fulcrum over which the tibia is broken. Spiral fractures occur

when the foot is stable and the body is twisted over the foot (Trafton 2003). Stress

fractures of the tibia result from repeated loading, with ultimate failure from fatigue.

Tibial stress fractures are mostly seen in the proximal physis of individuals (such as

soldiers, dancers, and runners) who place significant demands on their lower extremities.

Fractures to the distal end of the tibia (pilon) are most commonly caused by a fall from a

height, or by a motor vehicle accident (Bartlett et al. 1997). Forced abduction of the

pronated foot is responsible for many injuries to the medial and lateral malleoli. Usually

referred to as "twisted ankles", these injuries result from tension created by the pull of the

lateral or medial ligaments when the ankle is sharply inverted or everted, as when one

falls off a curb. Falls from heights or motor vehicle accidents account for most foot

injuries (DiGiovanni et al. 2003).

Interpersonal Violence

In general, craniofacial trauma tends to be more indicative of interpersonal

aggression. Victim identity is focused in the face, and thus aggression to the individual is

often directed there (Galloway 1999). In addition to the face, Fonseka (1974) found that

the thorax and ventral surfaces were areas most injured during episodes of spousal abuse.

Appendicular trauma tends to be more suggestive of accidental situations. Fractures to









the wrist and ankle commonly result from falls, especially in uneven terrain (Wells

1964).

The distinction between accidental and intentional injuries is blurred; attempts to

define the behavioral mechanism behind injuries are difficult, and should be pursued with

caution. The distinction between accidental- and violent-based skeletal trauma is highly

dependent on cultural influences. Attempts to determine the mechanism of trauma in

skeletal remains must be made in a contextual manner, where the examination of the

entire skeleton, when possible, can lead to more accurate determination of the manner in

which injuries were sustained.

Although many studies have addressed the physical manifestation of aggressive

versus accidental trauma, just as many have failed to adequately propose a set pattern for

skeletal expression distinguishing between the two. While due partly to differing

documentation protocols, what seems to be missing from the mass of literature is the

notion that aggression is dictated mainly by cultural norms. Every society will have its

own mode of dealing with stressors, whether they are of environmental or behavioral

origin. The physical display of intentional violence will thus show much intercultural

differentiation.














CHAPTER 3
RELEVENT BIOARCHAEOLOGICAL LITERATURE

Archaeologically, evidence of traumatic injuries are seen as bony changes

associated with fractures, callus development, remodeling after joint dislocations, and

ossifications that occur within injured muscle, tendon, and periosteum. From a

behavioral perspective, it is important to distinguish among injuries suffered before death

(antemortem) and those around the time of death (perimortem). For an injury to be

considered antemortem, evidence of healing must be present. In antemortem skeletal

injuries, fracture edges are either rounded, have woven callus formation, or are

remodeled, depending on how long the individual lived with the injury. Perimortem

injuries are distinguished from postmortem damage by the lack of healing activity, by

differential coloration of fractured ends, and by properties of the fracture. The diagnostic

features of fractures produced by blunt, sharp, or projectile forces and the principles

guiding the interpretations of proximate cause are well understood by forensic

anthropologists. The ultimate cause is much more difficult and requires consideration of

both intrinsic biological variables such as age and sex, and extrinsic factors relating to the

physical and sociocultural context (Walker 2001).

Archaeological research has highlighted the importance of sociocultural and

ecogeographic factors in trauma occurrence. Using a prehistoric Indian sample from the

Channel Island area of southern California, Walker (1989) demonstrated the influence of

local economy on skeletal injury. Numerous cranial wounds found were attributed to

intentional violence resulting from resource competition stress in the geographically









circumscribed area. Similar resource competition and resultant warfare are also cited as

explanations for like trauma found in several other locations, including the late

prehistoric sites in Illinois (Milner et al. 1991) and Tennessee (Smith 2003), late

Woodland Michigan (Wilkinson & Van Wagenen 1993), precontact central California

(Jurmain & Bellifemine 1997), and the preceramic Chinchorro population from northern

Chile (Standen & Arriaza 2000). In the late Woodland Michigan site, in particular,

numerous females were found with cranial fractures. These injuries are suggested to

originate from both spousal abuse and violence associated with female capture during

warfare.

Other significant bioarchaeological literature has shown the absence of trauma

stemming from aggressive behavior. Hershkovitz and colleagues (1995) found a very

low percentage of violent trauma in a collection of exclusively male skeletons associated

with a Byzantine monastery in Judean Desert. The authors attribute the lack of cranial

trauma to isolation from the secular population, regular food supply and absence of

warfare. In a late Woodland foraging group from Ohio, Lovejoy & Heiple (1981) found

evidence of mostly accidental traumatic episodes, with the highest frequencies found in

young males and females. The lack of sex differential in injuries suggests that warfare

was not the cause. Additionally, Smith (1996) found no sex bias in tandem parry

fractures to the ulna and craniofacial injuries in a large sample from late archaic

Tennessee. If a significant number of females had been found with such injuries, it might

suggest sex-specific abuse where blows to the head and face were deflected with raised

arms.









Geographic factors have been associated with elevated skeletal injuries and

reported in bioarchaeological studies. The uneven physical terrain of Nubia is suggested

as the particular cause of elevated accidental appendicular fracture frequencies found at

the neighboring sites of Semna South (Alvrus 1999) and Kulubnarti (Kilgore et al. 1997).

Both sites are in the Batn el Hajar region just south of the Egyptian border, an area

characterized by a dry and boulder-strewn landscape.

Skeletal Trauma Studies Using Greek Collections

Mediterranean archaeological sites, and Greek sites in particular, are infamous for

poor skeletal preservation. Thin-to-absent topsoil and wildly fluctuating temperatures

both result in speedy degradation of delicate bones. However, a few collections from

Greece and other neighboring Mediterranean sites have survived these environmental

challenges. J. Lawrence Angel, the late Smithsonian Institution physical anthropologist,

published numerous site reports on Mediterranean skeletal material from the early 1940s

through the mid 1970s. His reports are of varying length and detail, and customary of the

time, are found in the appendices of archaeological site reports. Although Angel was

primarily interested in tracing Greek social biology through cranial morphometrics

(Angel 1944, 1946), he also attempted to document traumatic and pathological lesions

found on archaeological remains.

Franchthi Cave

In a report on the skeletal remains from Franchthi Cave, Angel (1969) described

trauma he observed on 10 individuals from this early Mesolithic to late Neolithic site in

southern Greece. One adult male in the collection had a "vertical scar down his right jaw

ramus" and a young adult female had "injured knuckles of [the] left hand" (Angel

1969:380). Another young adult male exhibited healed fractures of the left 1st









carpometacarpal joint and 2 healed depressed fractures of the frontal bone above the

browridge. No illustrations were provided of these injuries, nor does Angel speculate on

the behavioral mechanism associated with the trauma.

Catal Huyuk

Angel's (1971a) thorough work at Catal Huyuk in Turkey provides a glimpse into

the early farming/proto-city lifestyle of people during the early Mediterranean Neolithic.

Social differentiation of trauma is evident in the frequency of skull wounds found in the

Catal Huyuk sample. Six of 22 adult male crania exhibit vault injuries, while only 2 of

32 females express similar trauma. Unfortunately, no description of the head injuries is

presented, thus limiting any speculation on the possible cause of the trauma. The fact

that 27% of males exhibit injuries compared to only 6% of females provides some

possible evidence of (intramale) violence. Fractures of the clavicle, humerus, ulna,

radius, and femur are also found on various individuals and are suggestive of accidental

trauma. Angel provides interesting scenarios for these injuries, ranging from bull goring

incidents to falls from house ladders in the dark (Angel 1971a). There is no sex bias in

any of these postcranial injuries.

The most noted skeletal pathology of this sample is porotic hyperostosis, which

results from anemia severe enough to cause hypertrophy of the vault diploe. Of the 143

adults, 41% display this characteristic thickening. The location of Catal Huyuk on the

inland drainage of the Konya Plain meant certain and close contact with anopholine

mosquitoes, which are transmitters of thalassemia, a Mediterranean version of malaria.

In addition to anemia, stresses from hunting, warfare, and trading trips would perhaps

have introduced sufficient life stresses to result in interpersonal violence.









Postural indicators are found on numerous individuals in this sample and provide

some indication as to how these people interacted with their environment. Reactive areas

on the femoral neck (Allen's and Poirier's fossae) are frequent. These lesions develop

when the ilio-femoral ligament is pressed against the zona orbicularis during running or

descending a slope. Such lesions are found in 70% of adult males and 84% of adult

females. Their frequent presence, in addition to the number of distal appendicular

fractures, suggests interaction with rough terrain. Squatting facets (depressions on the

distal tibia and/or superior talus) are found on approximately 50% of adult tibiae and tali

and suggest marked ankle flexion associated with a squatting posture and/or frequent

climbing.

Additionally, numerous individuals in the collection (46% of 43 femora) have a

backward direction of the lesser trochanter. The iliopsoas tendon inserts at this area and

serves as a lever to tighten flexion and rotation of the hip. This posterior twisting of the

lesser trochanter may be another reaction to flexion and stability of the thigh necessary

for frequent climbing; although Angel suggests that the twisting developed to supply

added leverage for quick turning and poising needed in dancing or animal games, as

shown in frescoes of this time period (Angel 1971a).

Lerna

Angel (1971b) found similar postural indicators in individuals from Lerna, an early

Neolithic to Roman era site on the Argos Plain of the Peloponnese peninsula. Evidence

of strong hip muscle development and frequent squatting facets indicate that climbing or

descending steep terrain was a common occurrence. Evidence of possible intentional

trauma is seen in fractures to the ulna, 5th metacarpal (boxer's fracture), nasals, scapula,

and vault. The overall frequency of these injuries is low (10% of the sample) and the









distribution of injuries is equally spread between males and females. The collection is

quite fragmentary, however, and true frequencies may be higher.

The Middle Bronze Age people of Lerna represent the start of a proto-urban

tradition. The era is a cultural spinoff from the transition from hunting, gathering, and

settled farming to urban trade and unification, and is presented by Angel as a time of

relative prosperity and cultural infusion. The general health of the individuals from this

time period is somewhat better than it is for those from earlier occupations. Porotic

hyperostosis from thalassemic malaria is seen in 26% of subadults and 16% of adults

(Angel 1971b). Additionally, signs of seasonal malnutrition or severe childhood disease

occurring as growth arrest lines on tooth enamel are minimal.

Khirokitia

Earlier, Angel (1953) examined the skeletal remains of 45 subadults and 78 adults

from Khirokitia, a Neolithic farming village site on the Mediterranean island of Cyprus.

Craniofacial trauma is found on 3 of 39 adult male crania. Injuries are seen especially on

the zygomatic, frontal, parietal, and occipital bones. Angel does not provide detailed

descriptions of the injuries, nor are photographs provided. He suggests that the

craniofacial trauma is of sharp force origin, although the injuries could represent healed

linear blunt force fractures. All cranial trauma is found exclusively on males, suggesting

that the injuries are of an intentionally violent origin. Certain metric and genetic

observations of this collection, such as short-headedness, paedomorphism, and metopism

are presented as strong evidence that the Khirokitians were an inbred and parochial

population that had few contacts with other breeding groups. Indeed, the high infant

death rate, short life span, and short adult stature in the group may be evidence that the









Khirokitian villagers had little leisure time and were more concerned with trying to stay

alive (Angel 1953).

Karatas

Angel's long-term work at the Turkish necropoli at Karatas (1966, 1968, 1970,

1976) has provided valuable information regarding life during the early to middle Bronze

Age on the Anatolian plateau. It is a large sample (n=584) important for its information

on the health and population changes made during the development of a proto-urban

economy out of an early farming subsistence. Cranial vault injuries are found on 5 males

and 1 female (over 10% of all intact crania) and suggest warfare or some other form of

intentional aggression (Angel 1970). Injuries are of blunt force and sharp force

mechanisms (depressed fractures and axe wounds, respectively). Fractures to the

midshaft of the ulnae are seen on 4 of 50 male ulnae and 1 of 30 female ulnae. Femoral

shaft fractures occurred in 1 of 122 male femora, and 2 of 160 female femora. Schmorl's

herniations and fatigue fractures of the 5th lumbar vertebrae are cited as common,

although no percentage frequencies are provided (Angel 1970). Minor postcranial trauma

found on the femora, tibiae, clavicles, humeri and radii occur equally between the sexes.

Cephallenia

In a series of 40 crania from 5 different cemeteries dating to the 12th century B.C.,

from the Mediterranean island of Cephallenia, Angel (1943) found that 32-47% of each

subsample exhibits cranial injuries. All injuries were found in males, with the exception

of 1 female bearing a depressed fracture to the right parietal. Trauma resulting from

sharp force injury was found on 5 males, with 4 of them occurring on the left side. One

other male had a fractured left zygomatic bone of blunt force mechanism. The

preponderance of sharp force trauma in males, in addition to the frequency of injuries on









the left side of the skull, demands an ethnological explanation. Angel notes that the

decline of the Mycenaean civilization that occurred during the 12th century B.C. may

have resulted in physical encounters with invaders from the west. Additionally,

participation in the Trojan War would explain the frequency of violent trauma found at

this site (Angel 1943).

Other sites

Other reports exist describing Greek skeletal trauma found on remains from Lema

(Wesolowsky 1973), Nichoria (Wade 1983; Bisel 1992), Attica (Angel 1945), Corinth

(Angel & Bums 1973), Diros (Papathanasiou et al. 2000) and the Athenian Agora (Little

& Papadopoulos 1998). However, these reports focus on either single, unique individuals

or on remains far too fragmentary or commingled to provide adequate comparative data.

Poor preservation aside, a few observations may be made after reviewing Angel's

anthropological reports. The relatively high frequency of fractures to the distal

extremities in the majority of samples is suggestive of consistent interaction with the

rough, sloping and mountainous terrain characteristic of Greece. Indeed, the prevalence

of postural indicators (i.e., squatting facets, Allen's fossae) and the degree of muscular

development among the individuals supports this assumption. There is also a relatively

high frequency of cranial trauma suggesting elevated cultural stressors such as

interpersonal (intramale) aggression, internecine warfare, and defense of the community

against warring invaders.

Table 3-1 compiles Angel's more notable skeletal analyses of Greek and Turkish

sites discussed above. When Angel gave information on whether injuries were found in

males or females, it is indicated. It should be remembered that skeletal trauma was not

the focus of Angel's work. Thus, blank cells do not necessarily mean that injuries were






22


absent. In many of his reports, postcranial trauma was not discussed at all. Actual

cranial and postcranial trauma occurrences are likely higher than reported, as the

archaeological material Angel analyzed tended to be quite fragmentary.













Table 3-1. Summary of skeletal analyses of Greek and Turkish archaeological sites published by Angel
Site Francthi Cave Catal Huyuk Lerna Khirokitia Karatas Cephallenia


Publication year

Time/Cultural period


Total sample size

Usable sample size

Cranial trauma
Postcranial trauma
Shoulder girdle
Sternum
Vertebrae
Pelvis
Humerus
Forearm/Hand
Femur
Leg/Foot


1969


Early Mesolithic- Late
Neolithic


10

10

2m


1971a


Neolithic


288

288

6 m, 2 f

1


1971b


Middle
Bronze Age


1953


1968, 1970


Neolithic Early-Middle
Bronze Age


234

234

2


540

534

5 m, 1 f


1943


12th cent. B.C.


44 (crania)

40

8 m, 1 f


1 m, 1 f


1 m, 1 f
1














CHAPTER 4
RELEVANT CONTEMPORARY LITERATURE

Contemporary clinical research has shown that socioeconomic variables such as

income, education level, minority/ethnic status and substance abuse are all significantly

correlated with overall trauma frequencies in hospital patients (Harries 1997; Cubbin et

al. 2000a; 2000b; Faelker et al. 2000; Lyons et al. 2000; Wagner et al. 2000; Hasselberg

et al. 2001; Blakely et al. 2002). These same variables also influence the frequency of

abuse to women, children and elders (Breiting et al. 1989; Grisso et al. 1999; Kyriacou et

al. 1999; Caetano et al. 2000; Cunradi et al. 2000).

Figure 4-1 graphically displays the general relationship between socioeconomic

status and trauma frequency among hospital patients. Deprived individuals are

collectively those with low income, low education, minority status, history of substance

and alcohol abuse, incarceration and high unemployment rate. Conversely, affluent

individuals are those with relatively higher income, higher education, majority status, less

substance and alcohol abuse, and higher employment rates. As one's socioeconomic

status improves, or becomes more affluent, one's overall frequency of trauma tends to

decrease.

Social researchers have also found socioeconomic status to be an important factor

in the type of skeletal injury encountered. Lyons et al. (2000) addressed the influence of

annual family income on childhood trauma in their study of injuries in affluent and

deprived areas of Wales. When matched for sex and age, children from wealthier areas









had higher rates of sports-related fractures while those in poorer areas had more assault-

related injuries. In addition, poorer children had considerably higher rates of death from

injury than their more affluent counterparts. Moustaki et al. (2001) noted a lower overall

injury rate in Greek children as compared to this same Welsh sample. They recorded a

rate one-third the frequency found by Lyons et al. (2000), citing the better nutrition of

Greek children as the biological mechanism for this decrease; presumably the better diet

of Greeks led to stronger bones and less fractures. Greek children did, however, have

twice as many cranial fractures as the Welsh sample. Variation in preventive measures

(lack of safety helmet use) and geographic qualities (rocky terrain) are given as reasons

for this difference.




Trauma
frequency

deprived affluent
Socioeconomic status
Figure 4-1. General relationship between socioeconomic status and trauma frequency
among hospital patients

An enormous amount of clinical literature on skeletal trauma exists in relevant

medical journals. Most reports are based on hospital admittance records. The majority of

reports, however, are case studies focusing on specific regions or elements of the body,

such as the craniofacial skeleton (Schultz 1967; Luce et al. 1979; Voss 1982; Brook &

Wood 1983; Scherer et al. 1989; Hussain et al. 1994), upper limb (Alffram & Bauer

1962), wrist (Fleege et al. 1991), and foot (Wenig 1990; Koch & Rahimi 1991).









Few clinicians have attempted a systematic approach to skeletal trauma, and those

that publish such data lack a sociocultural approach in their analysis. Buhr & Cook

(1959) describe fracture patterns in a sample composed of British hospital admission

records for the years 1938 through 1955. Fractures (no other skeletal trauma were

investigated) were considered only by age and sex of the injured. The authors found that,

below age 50, fractures occurred mostly in males, but above that age there was a sharp

increase of trauma to women. By the decade 70-79 years, there were four times as many

women with fractures as men. In a similar study of British hospital records, Donaldson

and colleagues (1990) reported on age and sex specific fracture rates in a 3-year patient

cohort in the early 1980s. The authors found an identical elderly female dominance in

fracture frequencies with age-related disease cited as the mechanism behind most

injuries. Sahlin (1990) analyzed the incidence of fractures according to age, curiously

omitting sex as a variable. Using admittance records of a Norwegian hospital from 1985-

1986, he found advanced age to be the most important variable in fracture occurrence.

Harries (1997) provides an interesting report focusing on the influence of

sociocultural stress and physical trauma. Using an epidemiological approach, the author

investigated spatially distributed phenomena (violence) and the conditions (social

stresses) associated with them. A stressorr" is defined as a condition producing some

degree of social dysfunction. The stress of poverty was most influential and was

accompanied by a related set of deprivations in housing and other basic necessities.

Using a number of variable stressors (including the number of homicide/aggravated

assault incidents, large households with no male figure, unemployment, poverty levels,

vacant housing units nearby, adult per capital income and education level), Harries found









clusters of specific areas with shared traits in terms of the underlying set of stressors.

Harries did not focus on specific, physical examples of trauma. Rather, he used a public

health approach to investigate why certain areas in an urban setting were exhibiting high

frequencies of trauma.

Research based on contemporary skeletal sample populations is scarce, due mainly

to the limited number of available collections. At present, there are two large and

relatively well-documented accessible collections, both of which are composed mostly of

American individuals who either willed their bodies to science or who were unclaimed

hospital deaths. The Hamann-Todd Osteological Collection at the Cleveland Museum of

Natural History consists of the skeletal remains of anatomical specimens who were

originally unclaimed bodies retrieved from the nearby county morgue and city hospitals

from 1893-1938 (Jones-Kern & Latimer 1996). The Robert J. Terry Anatomical Skeletal

Collection curated at the National Museum of Natural History at the Smithsonian

Institution consists mainly of cadaver skeletons retrieved from the Washington University

Medical School. These bodies were primarily obtained from hospital and institutional

morgues in the St. Louis, Missouri area from 1920-1967 (Hunt DR, August 17, 2004,

www.nmnh.si.edu/anthro/cm/terry.htm). The collection also contains some individuals

who donated their bodies to science.

Although much skeletal research has been done using these two samples, studies

focusing specifically on trauma are curiously limited. Mensforth et al. (1987) and

Mensforth & Latimer (1989) observed fracture patterns of specific elements of

individuals in the Hamann-Todd collection and compared them to the same injuries in

individuals of slightly more contemporary origins. Angel (1974) included a sub-sample









from the Terry Collection who had willed their bodies to science in his report on the

comparative fracture patterns of individuals from the Neolithic to modern times. Angel

specifically ignored the dissecting-room component of the collection, believing that

"disadvantaged people exposed to tougher genetic, nutritional, and socioeconomic

forces... [were] not comparable with ancient populations" (Angel 1974:9). Angel

assumed the health of the contemporary industrial city-dweller was worse than that of the

archaeological sample, although a large suite of environmental stressors no doubt

affected the ancient groups as well. Lastly, Walker (1997) included a sample of crania

from both the Terry and Hamann-Todd collections as part of a larger study examining the

skeletal evidence for the cultural patterning of violence in diverse Western populations.

Most of these studies focused on specific anatomical elements or regions of the

skeleton. The researchers thus assume that trauma found at various sites is predictive of

overall accidental or aggressive behavior. Walker (1997) assumes that certain cranial

injuries are more predictive of intentionally violent situations than other regions and he

omits the postcranial skeleton in his study. Although Mensforth et al. (1987) indicate

they were only looking for fracture patterns in certain bones, the inclusion of the entire

skeleton would have provided a more accurate picture of the behavior associated with

trauma. Indeed, in a study on the skeletal trauma manifestations of patients involved in

domestic assault versus accidents in a modern British casualty unit, Novak (1999) found

the coexistence of certain injuries to be most predictive of behavior. Tandem

craniofacial, thoracic and distal upper extremity injuries were more often associated with

domestic assault while isolated fractures to the upper and lower distal extremities were

more predictive of accidental episodes. Thus, if preservation allows, an examination of






29


the entire skeleton is necessary when one attempts to decipher the ultimate mechanism of

trauma. Selecting specific elements may ease analysis, but it presents an artificial

isolation of elements, and therefore introduces bias.














CHAPTER 5
SOCIOECOLOGICAL ASPECTS OF PRIMATE BEHAVIOR AND TRAUMA

Research on primate behavior is of interest to anthropologists because, to the extent

that non-human animals engage in planning, cooperation, and manipulation of

individuals, relationships, and alliances, their behavior must involve features which are to

some degree similar to those which characterize human behavior (Quaitt & Reynolds

1993). Anthropologists look to our primate cousins to discover characteristics that are

shared among the humans and non-human primate evolutionary continuum. Primate

studies are also pursued to discover characteristics that are distinctly human, as opposed

to those that might be part of the primate heritage.

Of special interest to primate socioecological research is the focus on within- and

between-group competition. Competition can be defined simply as when species

simultaneously seek essential resources of an environment that are in limited supply, be

they food, social/sexual partners or safe places to live or hide (Sussman 1999).

Competition depends on the availability and distribution of resource items, the

monopolization of which plays a part in structuring the nature of social relationships

between members of a primate social group (Van Schaik 1989). In order to acquire

resources, it pays for an individual to invest in behavioral dispositions that increase his or

her superiority. Consequently, there will be a selective pressure toward individual

dispositions that are dominance-oriented.









Population Density and Resource Availability

Ecological theories on aggressive behavior hold resource scarcity to be the crucial

determinant in human societies (Harris 1974, 1979; Ross 1985, 1986). Likewise, in cases

where preferred or necessary food items are naturally restricted to a few places, conflict

and high levels of intragroup aggression are also observed in non-human primate groups

(Nagel & Kummer 1974). Borries and colleagues (1991) found that in saturated habitats

of Hanuman langurs, rates of within-group aggression are more elevated than they are in

groups living at lower population densities with more abundant food supplies. Here, one

would expect environmental circumstances to affect the frequency of aggressive acts.

Diminished resources increase the importance of winning; it seems only logical,

therefore, to predict an increase in antagonistic behaviors under such circumstances.

Food shortages should result in increased competition and status hierarchies representing

the order of access to food.

Primate research on population density and aggressive behavior among various

species also reports conflicting results, however. In a study of chimpanzees living at the

Yerkes Regional Primate Research Center, Aureli & deWaal (1997) found that the rate of

agonistic behaviors actually occurred less frequently under high-density conditions. This

was interpreted as an inhibition strategy to reduce opportunities for conflict when

interindividual distances were reduced. This strategy was effective only in the short run,

however, as anxiety levels were simultaneously elevated, suggesting increased social

tension under high population density conditions. When free-ranging rhesus monkeys in

Cayo Santiago were faced with a temporary food shortage, the frequency of fights

decreased significantly while the frequency of grooming, play and mating also decreased.

The animals became socially lethargic and spent most of the time slowly searching for









food (Loy 1970). Southwick (1976) noted that food shortages also resulted in decreased

agonistic encounters among rhesus monkeys in Calcutta. Fighting, grooming, playing

and mating behavior simultaneously declined during food shortages, suggesting tension

was present even if outwardly agonistic behavior was not.

Additional research suggests that primates use various affiliative mechanisms (i.e.,

hand-holding, altruistic behavior) to adjust their behavior when population density

increases such that potentially adverse consequences of crowding and food shortages are

present (Bercovitch & Lebron 1991). Social stability then, tends to be a more important

determinant of primate aggression than population density.

Studies on human aggression suggest that cultural features may likewise override

ecological factors involved in agonistic behavior. Robarchek & Robarchek (1992)

performed a comparative study on two equatorial societies in an effort to determine what

factors were involved in aggressive behavior in two eco-geographically similar societies.

The warlike Waorani of the Ecuadorian Amazon live in a low population density region

with plentiful resources. There are no specific cultural or individual values to maintain

group cohesion and thus no internalized controls on conflict or violence. The Semai

Senoi of the Malaysian rainforest experience higher population density with scarcer

resources. Violent behavior is heavily constrained, however, by individual and cultural

values that stress nonviolence, and by the internalized need to avoid any disruption within

the kindred and band. Thus, differing cultural constructions between the two groups

structured their behavior.

Infanticide

Darwin's sexual selection hypothesis is believed to play an important role in the

systematic or opportunistic killing of infants (Darwin 1871). Sexual selection refers to









the struggle between one sex for access to the other with the result for the unsuccessful

competitor being not death, but fewer or no offspring. A male increases his reproductive

success by killing unrelated infants if the infant's death makes the mother resume estrus

sooner than she would otherwise. Unweaned infants are at the highest risk (Hrdy et al.

1995).

In addition to sexual selection, infanticide may occur as a response to competition

for territory and food resulting from environmental pressures (Hrdy & Hausfater 1984;

Hrdy et al. 1995). Roda & Pontes (1998) documented targeted killing of unweaned

infants in a group of common marmosets as a consequence of environmental disturbance.

The population had surpassed the limited carrying capacity of the environment, which

increased competition for food, mates, and territory. Troop members had no opportunity

to set up territories elsewhere and so were forced to compete for the scarce resources in

their natal group.

Infanticide may also act to reduce the number of future competitors in a group.

Newton-Fisher (1999) observed two cases of male infanticide by extra-troop males in

wild chimpanzees. By reducing the number of males reaching adulthood in a

neighboring community, the aggressors reduce its territorial strength, which in turn

makes range expansion, recruitment of females, and extinction of the neighboring

communities more feasible for the infanticidal males. Arcadi & Wrangham (1999) found

male and female cooperation in infanticide. Females appear to gain long-term benefits by

reducing resource competition or the risk of their own infants being attacked. Males

benefit by spurring females into estrus sooner and eliminating future rivals. However,

the fact that some of the males were related to their victims and that some did not always









mate with the mother highlights how difficult it is to attribute infanticide to any one

explanation.

Field studies also show that increased general aggression toward females with

infants occurs during boundary patrols (Watts & Mitani 2000). Chimpanzees are often

seen cannibalizing the bodies of killed infants (Goodall 1986) suggesting that infanticide

may sometimes occur as a food resource exploitation.

Coalitionary Killing

Intercommunity relations among certain primate species are predictably hostile.

Muller (2002) found that coalitionary intergroup attacks are a regular feature of

Kanyawara chimpanzee society. Male activities during border patrols for territorial

defense are especially violent. Female chimpanzees are found to be aggressive primarily

in the context of feeding competition, although levels of interpersonal aggression are

rarely severe. One possible explanation is that competition for space is not as

pronounced as it is at other regions, thus the benefits of female competition for high rank

are less. Coalitionary attacks act to reduce the coalitionary strength of neighbors as well

as expand territories.

Other references cite tolerant and affiliative aspects of primate relationships,

especially in all-male groups. Examples include spider monkeys (Chapman et al. 1989),

squirrel monkeys (Boinski 1994; Mitchell 1994) and chimpanzees (De Waal 1982).

Primatologists have found that cooperation, bonding reciprocity and negotiation among

primate groups seems to depend partly on the degree of genetic relatedness (Van Hooff

2000).









Primate Trauma

Targeted aggression results, then, from an amalgamation of adaptive, ecological,

social, and physiological mechanisms. Environmental fluctuations influence the

regularity of food patches and in turn affect the social and physical well being of primate

troops (Roda & Pontes 1998; Saito et al. 1998). The introduction of stepparents or

sudden group movement may spur stress among troop members resulting in "social

pathology" (Snowdon & Pickhard 1999). Aggressive behavior may result from attempts

at population control (Digby 1999) or predation (Goodall 1986). Researchers have found

that aggressive behavior differs among species (Boinski 1999) and within species (Saito

et al. 1998), the latter suggesting that personality differences of troop members may

reflect an individual's own experiences more so than their genetic background (Clarke &

Boinski 1995).

Severe wounding or death from infanticide and generalized aggression are frequent

occurrences in most primate species. Various intraspecific social, physical, and

ecological processes influence injury caused by aggressive and accidental behavior.

Traumatic, healed fractures in primates occur in significant frequencies and may

reflect patterns of primate aggressive behavior as well as physical adaptations to

environmental settings and locomotor differences. There may be different intraspecific

"cultural" norms existing that regulate aggressive behavior. Individual personality

differences and the influences of life histories may also direct intraspecific injury rates.

Species may also be prone to sustain injuries because of the dangers of different

environmental settings (terrain, climate, predators). Such wide variances in fracture

frequencies may also be the result of differing documentation protocols with varying

ideas of what constitutes trauma. Most likely, all these factors come into play.















CHAPTER 6
MATERIALS AND METHODS

The following discussion describes in more detail the Greek sample used to address

the research objectives introduced earlier. Documentation protocols and statistics used in

this study are also provided.

The University of Athens Sample

The University of Athens (UA) skeletal sample is composed entirely of individuals

from an ossuary located in the eastern Athenian suburb of Zografou. They are the result

of recent exhumations within the last 5 years from a cemetery on the same grounds. The

remains have been donated to the University of Athens, Department of Human and

Animal Physiology for research purposes.

Greek culture follows pseudo-secondary burial practices. Unembalmed decedents

are initially buried for a period of three years to allow for complete skeletonization,

exhumed, and then finally stored (or re-buried) in individual containers in several large

repositories located on the cemetery grounds. Those individuals who had not made

provisions for the storage of their remains after exhumation are, after a period of time,

eventually pulled out of the repositories and disposed of in large communal underground

vaults (Appendix A). All the individuals in this collection have either been donated to

the University of Athens by family members of the deceased or are individuals who were

on their way to the communal bone vault (C. Eliopoulos, pers. comm.). Full and friendly

cooperation exists between the ossuary caretakers and the University of Athens.









Most skeletons were relatively free of soft tissue and odor on exhumation. Those

individuals who required further cleaning were immersed in a weak solution of warm

sodium perborate trihydrate for a period of 2-3 days in order to extract additional fat from

the bone. After cleaning, the bones were air-dried under a protective hood, labeled, and

then stored in archival boxes in the biological laboratory at the University of Athens.

Currently, 171 individuals are in the Greek collection, with additional remains

received periodically from the Zografou ossuary. The age at death, place of birth and

death, occupation, and cause of death are mostly known. A few caveats must be

presented explaining the quality of the data. While sex, age and places of birth and death

are established forthright, other variables are somewhat questionable. Cause of death as

listed on the death certificate is described interchangeably as either the primary or

secondary cause. Thus, an individual may exhibit obvious evidence of a long-term

systemic disease such as cancer, but the death certificate will cite the cause of death as

'acute respiratory failure'. Additionally, the last known occupation provided by the death

certificate is just that. In what aspect the individual was or was not employed preceding

the last known occupation is not known. Many of the individuals in this collection are of

advanced aged and are listed as pensioners, rendering the occupation variable unusable

for those individuals.

Methods

Individuals from the sample were examined for gross antemortem and perimortem

skeletal injuries. For an injury to be considered antemortem, evidence of healing must be

present. In antemortem skeletal injuries, fracture edges are either rounded, have woven

callus formation or are remodeled, depending on how long the individual lived with the

injury. Perimortem injuries are distinguished from postmortem damage by the lack of









healing activity, differential coloration of fractured ends and properties of the fracture.

Both sexes and all ages are included in this study. In addition to fractures, skeletal

evidence of soft tissue trauma (i.e., muscle and ligament injuries) was recorded. No

destructive procedures were undertaken.

The first data collection on a subsample (n=31) of the cemetery collection at the

University of Athens during the month of October 2001 served as a pilot study. For this

trip as well as the subsequent trip in September-October 2002, a thorough and efficient

recording protocol was developed. Protocols suggested by Lovell (1997) and Buikstra &

Ubelaker (1994) provided the bases for the documentation procedure. Data recording

included separate forms for inventory, morphological and metric assessments of sex, age

and pathology. The inventory forms recorded data on individual element preservation by

region and side. The pathology forms included detailed information on fracture type,

shape and sequelae. The length of the afflicted element, as well as the apposition,

rotation, and angulation at the fracture site were recorded. Observations were also made

for evidence of dislocations, amputations, arthritis (as possible evidence for joint injury)

and skeletal evidence of antemortem soft tissue trauma. Sample data collection forms are

located in Appendix B.

Although data on the sex, age, and ancestry for the Greek individuals were

already known from associated death certificates, confirmation of the biological profile

data was accomplished via morphological and metric assessments of diagnostic skeletal

features, the most accurate of which are found on the pelvis and cranium. For the pelvis,

Phenice's (1969) technique for adult sex determination on the pubic region was used.

This method includes examination of the ventral arc, subpubic concavity and ischiopubic









ramus. Additionally, the morphology of the greater sciatic notch and preauricular sulcus

were considered. On the cranium, development of the nuchal crest, mastoid processes

and supraorbital margins were further diagnostic indicators for sex.

Subadult sex determination is notoriously difficult due to the lack of sexually

dimorphic skeletal features, which are under hormonal control and thus do not appear

until puberty. Although features of the auricular surface (Weaver 1980; Mittler &

Sheridan 1992) and greater sciatic notch (Boucher 1957; Weaver 1980; Schutkowski

1993) are suggested as dimorphic in subadults, none of these methods is highly accurate.

Thus, morphological confirmation of sex determination on subadults was not attempted.

Adult age indicators were confirmed mainly from pelvic features. The

morphology of the pubic symphysis according to the Suchey-Brooks scoring system

(Suchey & Katz 1986; Brooks & Suchey 1990) provided the most accurate age ranges.

The appearance of the auricular surface of the ilium (Lovejoy et al. 1985) supplemented

age determination. Interestingly, age ranges produced using gross morphology of the

sternal rib ends (Iscan et al. 1984a, 1984b, 1985) did not appear to match the pelvic

indicators in this collection, indicating the need for a population-specific criteria. This

problem is currently being addressed in a forthcoming thesis by Mr. Constantine

Eliopoulos, MSc, in his research using this same collection. Lastly, the degree of cranial

suture closure (Meindl & Lovejoy 1985) and degree of vertebral arthritis and joint

degeneration (McKern & Stewart 1957) were used to confirm age in the absence of more

accurate criteria as well as to support age estimation.

Subadult age is determined mainly by long bone lengths, union of primary

ossification centers (Stewart 1979), tooth formation (Moorees et al. 1963a, 1963b), tooth









eruption (Schour & Massler 1941; Ubelaker 1999) and epiphyseal union (Buikstra &

Ubelaker 1994).

Determination of ancestry is best accomplished by examination of cranial

features. Morphological and metric aspects of the midfacial paranasall) area, facial

profile and vault shape have shown to be especially accurate for ancestral determination

(Krogman 1962; Byers 2002). Overall, contemporary Greeks conform to the classic

European standards of craniofacial morphology. Interestingly, personal observation of

the Greek sample showed frequent metopism in both males and females as well as

pronounced supraorbital ridge development in many females.

To explore statistical relationships among the data, the prevalence of trauma by

bone/region and the distribution of trauma patterns were tested for independence and

significance for each biological and demographic category (sex, age, cause of death, last

known occupation). Summaries of percentages, means, cross-tabulations, ANOVAs, chi

square tests for independence between variables and loglinear modeling of multivariate

categorical data explored patterns in the data.














CHAPTER 7
RESULTS

Descriptive Demographics of the University of Athens Skeletal Sample

Sex and Age

The total sample size from the University of Athens (UA) collection is 121

individuals. There are 62 (51.2%) males and 59 (48.8%) females. Ages span from 3 to

99 years. The overall mean age is 58 years. When the three subadults in the sample are

omitted (3, 6 and 14 years-old), the mean age increases to 59 years. Table 7-1 displays

the frequency of individuals in each age category by sex. Figure 7-1 shows how age at

death in this collection is skewed toward individuals in the middle adult to older adult

years for both males and females.

To compare the demography of the UA collection with the population of Greece

at large, the United Nations Economic Commission for Europe (UNECE) provides data

for Greece for the year 1997 (Table 7-2). This year was chosen as the target year for

comparison as this was when the majority of individuals in the Greek skeletal sample

died. Disparities in the percentages of individuals making up each age category between

the two groups do not actually indicate true population differences. Rather, the UA

collection was amassed primarily to establish new identification protocols (namely, aging

and sexing techniques) for contemporary Greeks. Individuals in the collection were

chosen specifically for skeletal preservation and specific age than for any true

demographic representation. Table 7-2 illustrates this bias in collection choices.









Table 7-1. Age category frequency by sex for the UA sample


Age category
0-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
85+
Total


Male


Female


Total
3
1
8
14
23
28
20
18
6
121


Table 7-2. Percentages of deaths by age category for UNECE data (1997) and the
UA skeletal sample
Age category UNECE* UA sample


0-14
15-24
25-34
35-44
45-54
55-64


2.5
0.8
6.6
11.6
19.0
23.1


65-74 21.8 16.5
75-84 32.0 14.9
85+ 27.4 5.0
*UNECE Statistics for Europe and North America, Demographic Database.


20


= 10

5



Oto 15to 25to 35to 45to 55to 65to 75to 85+
14 24 34 44 54 64 74 84

Age category



Figure 7-1. Age category frequencies by sex for the UA sample


-*- males
- females









Cause of Death

Causes of death as listed on associated death certificates ranged widely from

common cancer- and heart-related illnesses to infrequent drug overdoses and

asphyxiations. To facilitate statistical analysis, causes of death were compiled into

somewhat discrete categories (Table 7-3). Chronic diseases of the heart were overall the

most frequent illnesses leading to death in the UA sample, followed by numerous forms

of cancer.

For comparison, the World Health Organization (WHO) provides data on mortality

for all of Greece. Again, the year 1997 was chosen as the target year for comparison.

Table 7-4 lists select cause of death categories and frequencies for the UA sample and for

all Greeks who died in 1997. By and large, chronic cardiac- and cancer-related illnesses

are the leading causes of death between the two groups. Respiratory illness was not as

common as stroke in the Greek population at large in 1997; the opposite is true for the

UA sample. Renal and cerebral illnesses, in addition to suicide, remain the least frequent

cause of death among Greeks.

Occupation

Associated death certificates provide information on last known occupation for

nearly half of the individuals. Many in this collection are elderly pensioners and are

included in the unknown category. Table 7-5 graphically displays the distribution of last

known occupation among the UA skeletal sample. For comparison, Table 7-6 displays

employment categories and frequencies by select sectors for all Greek citizens during the

year 1997.











Table 7-3. Cause of death categories and frequencies for the UA skeletal sample
Cause of death Cause of death as listed on death n %
category certificate
Cardiac heart attack 43 35.5
heart failure
vegetative myocardis [sic]
Cancer generalized 37 30.6
colon
brain
liver
breast
stomach
cyst
pancreatic
ovarian
nasal
cervical
buccal
lymphoma
Respiratory pneumonia 11 9.1
respiratory infection
emphysema
lung edema
Stroke stroke 7 5.8
brain hemorrhage
subarachnoid hemorrhage
Other sipshaemic [sic] shock 6 5.0
digestive coma
choking
gangrene
gerontiki exantlisis
Trauma heavy craniocerebral injury 5 4.1
skull and brain trauma
Renal chronic renal deficiency 3 2.5
TB-C of kidney
Cerebral degeneration of brain 3 2.5
advanced necrosis of brain matter
Huntington's disease
Unknown unknown 2 1.7
Drug Overdose drug overdose 1 0.8









Table 7-4. Select cause of death categories and percentages for all Greek deaths in 1997
and the UA skeletal sample
Category All Greeks* UA sample
Cardiac 14.3 35.5
Cancer 23.4 30.6
Respiratory 3.5 9.1
Stroke 18.4 5.8
Trauma 2.3 4.1
Renal 1.5 2.5
Cerebral 1.6 2.5
Suicide 0.4 1.7
*Based on 99,738 deaths. Compiled from WHO Annual Statistics: Table 1: Numbers of
deaths and death rates. Greece, 1997.

Table 7-5. Occupation category, number and percentage for the UA skeletal sample
Occupation n %
Unknown 56 46.28
Domestic 36 29.75
Private sector 23 19.01
Military 5 4.13
Civil servant 1 0.83

Table 7-6. Select employment sectors, frequencies and percentages for Greece, 1997
Category n %
Private sector 2,886,600 27.5
Civil servant 967,500 9.2
Total employed* 3,854,100 36.7
Total unemployed* 440,400 4.2
*Based on individuals 15+ years of age. Compiled from The Yearbook of Labour
Statistics. International Labour Organization, Bureau of Statistics, LABORSTA,
Greece, 1997.

Trauma Frequencies

The skeletal remains of the individuals comprising the UA sample are very well

preserved. Brief burial time and careful handling by cemetery caretakers result in the

majority being fully represented. Injury frequencies were first calculated by the per bone

method (number of injured elements divided by the number of elements present). Injury

frequencies were also calculated by the per individual method (number of injured










elements divided by the number of individuals present). Finally, injury frequencies were

calculated by sex. See Table 7-7.

Table 7-7. Trauma frequency percentages by element for the UA skeletal sample.
Element % per bone % per % per male % per
individual female
Facial 12.7 12.4 21.9 1.8
Cranium 11.7 11.6 14.1 8.8
Cervical vertebrae 2.5 5.8 6.2 5.3
Thoracic vertebrae 7.3 26.4 29.7 22.8
Lumbar vertebrae 3.6 11.6 15.6 7.0
Sacrum 11.2 9.1 7.8 10.5
Left rib 5.1 26.4 26.6 26.3
Right rib 5.6 27.3 25.0 29.8
Sternum 3.1 2.5 0.0 5.3
Left clavicle 1.8 1.7 3.1 0.0
Right clavicle 1.7 1.7 3.1 0.0
Left scapula 1.7 1.7 1.6 1.8
Right scapula 2.5 2.5 3.1 1.8
Left humerus 4.2 4.1 4.7 3.5
Right humerus 5.1 5.0 4.7 5.3
Left ulna 7.8 7.4 10.9 3.5
Right ulna 5.2 5.0 4.7 5.3
Left radius 12.2 11.6 10.9 12.3
Right radius 8.5 8.3 9.4 7.0
Left carpal 2.0 2.5 4.7 0.0
Right carpal 3.3 3.1 3.5
Left metacarpal 1.1 3.3 4.7 1.8
Right metacarpal 3.3 4.7 1.8
Left carpal phalanx 0.2 0.8 1.6 0.0
Right carpal phalanx 0.0 0.0 0.0
Left pelvis 2.5 2.5 1.6 3.5
Right pelvis 4.3 4.1 4.7 3.5
Left femur 5.9 5.8 4.7 7.0
Right femur 12.0 11.6 14.1 8.8
Left patella 0.0 0.0 0.0 0.0
Right patella 3.2 1.7 0.0 3.5
Left tibia 8.4 8.3 10.9 5.3
Right tibia 3.4 3.3 3.1 3.5
Left fibula 5.1 5.0 4.7 5.3
Right fibula 1.7 1.7 3.1 0.0
Left tarsal 1.3 5.0 6.3 3.5
Right tarsal 1.1 4.1 7.8 0.0
Left metacarpal 0.8 6.6 6.3 7.0
Right metacarpal 2.5 3.1 1.8
Left pedal phalanx 1.7 3.1 0.0
Right pedal phalanx 2.5 3.1 1.8









Statistical Results

In order to address the research objectives presented in Chapter 1, numerous

statistical analyses were performed. Power analysis tested for sample size adequacy.

Next, each research question is addressed. The prevalence of trauma by bone/region and

the distribution of trauma patterns were tested for independence and significance for each

biological and demographic category (sex, age, cause of death, last known occupation).

Summaries of percentages, means, cross-tabulations, ANOVAs, chi square tests for

independence between variables and loglinear modeling of multivariate categorical data

explored patterns in the data.

Sample size adequacy is tested via power analysis. In order to maximize the

chances of estimating a sample statistic that closely approximates the actual parameter,

power analysis ensures that the sample size is adequate. The sample size for this study is

based upon a statistic that is statistically significant at the 0.05 level, with a 5%

confidence interval using the following formula proposed by Krejcie & Morgan 1970:

sample size =
X2NP(1-P)
C2(N-1)+ X2P(1-P)

where: 2 = chi-square formula for 1 degree of freedom (X2 = 3.841)
N = population size
P = population parameter of a variable (P = 0.5)
C = confidence einterval (5%)

The current population size of the UA sample is 171. Using this equation, a

statistically adequate sample size for this research is 188 individuals.


(3.841)(171)(.5)(.5)
(.05)2(170) + (3.841)(.5)(.5)









Research Question 1: Does the Relatively Low Socioeconomic Status of the Average
Athenian Result in Increased Trauma in the UA Sample?

Compared to neighboring Balkan and Mediterranean countries, Greece appears to

prosper in certain socioeconomic aspects such as average annual income, level of

education and annual expenditure on health (Table 7-8). However, when viewed against

other westernized countries with cosmopolitan and economically competitive urban

centers such as the United States and Italy, the population of Greece has comparatively

low socioeconomic levels. This disparity reflects Greece's political, economic and

geographic location as a crossroads between Balkan repression and the modern European

economy.

Since entering the European Union in 1981, Greece's economy has rapidly changed

from a focus on the provincial agricultural lifestyle to an increased urban service industry

catering to the needs of modernization. Greece's claim on the commercial shipping

industry has grown during the last two decades to assume 9% of the global merchant fleet

(U.S. Dept. of State Post Report 2003). Despite recent urban modernization, this is still a

country that must import most of its food, machinery and raw materials.

Greece depends heavily on tourism for national income. Of the 71.6% gross

domestic product provided by the service sector in 2003, over 7% originated from

tourism receipts alone (UNECE Trends in Europe and North America, 2003). This

limited, tourist based economy is especially felt in Athens with its focal resource

competition and confined, physically treacherous environment. Additionally,

unemployment in Greece has remained consistently high for the last decade and at 10.2%

in 2001, it was the second highest rate in the European Union (UNECE Trends in Europe

and North America, 2003).









Table 7-8. Select socioeconomic indicators for Greece, neighboring Mediterranean
countries and the U.S.


Socioeconomic
indicator
Average annual
income per capital
(USD), 2001
Tertiary education,
total students per
1,000 pop., 2001
Total expenditure
on health (%
GDP), 2001
Life expectancy at
birth (yrs), m/f,
2003
Unemployment
rate, 2001
Average household
size, 2000
Population density
per km2, 2003
% urban, 2003
Population growth
(%), 1995-2000
Number residing
foreigners
(thousands) and
largest foreign
nationality, 2001


Greece Cyprus Turkey


11,499



31



9.2


7,932



16



6.0


4,279


FYRM* Italy


3,739 15,863 24,436


75.4/80.7 65.3/67.2 66.8/72.5 70.5/74.8 76.7/82.9 74.1/79.5


10.2


3.0


80


60
0.16


4.0


3.1


82


70
1.06


161.1
Russian
Fed.


8.5


4.6


87


66
1.63


30.5


79


59
0.61


246.7


Germany


192


67
0.16


1464.6 30466.0
Morocco Mexico


*Former Yugoslav Republic of Macedonia. Compiled from UNECE Trends in Europe
and North America, The Statistical Yearbook of the Economic Commission for Europe,
2003.
Given Greece's marginal socioeconomic levels, it is surprising that crime and

violent mortality rates in the country are among the lowest in the EU and also well below

the United States (Tables 7-9 and 7-10). Overall homicide rates are below the EU


U.S.


53



14.0


30


77
1.06









average and suicide rates continue to be the absolute lowest for all reference countries

(lerodiakonou et al. 1998).

Table 7-9. Crime indicators, per 100,000 population, for Greece and the U.S., year 2000
Greece U.S.
Serious assault 69.8 323.6
Reported rapes 2.3 32.1
Robbery, violent theft 16.6 144.9
Homicides 2.8 5.5
Compiled from INTERPOL International Crime Statistics 1989-1990 and 2000,
www.interpol.int/Public/Statistics/ICS, and the Fifth United Nations Survey of Crime
Trends and Operations of Criminal Justice Systems, 1990-1994, UNCJIN.

Table 7-10. Violent death rates per 100,000 population for males/females, Greece and
the U.S., year 1997
Greece U.S.
Suicide 6.2/1.0 18.7/4.4
Homicide 2.6/0.6 13.8/3.9
Compiled from WHO Annual Statistics, Table 1: Numbers of death and death rates.
Greece, 1997, and United States of America, 1997.

Socioeconomic variables such as low income, low education, high unemployment

rates and high population density are significantly associated with increased frequencies

of assault, abuse and other violent crimes. Accordingly, one should expect to see

increased frequencies of skeletal trauma in a sample based on a population with low

socioeconomic status. Instances of poorly set or non-treated fractures where individuals

either could not afford adequate medical care or it was simply not available might be

found.

As stated in Chapter 2, craniofacial trauma tends to be more indicative of

interpersonal aggression. Victim identity is focused in the face and thus aggression to the

individual is often directed there (Galloway 1999). In addition to the face, Fonseka

(1974) found that the thorax and ventral surfaces were areas most injured during episodes

of spousal abuse.









Only twelve individuals (9.9%) in the UA sample display antemortem, non-motor

vehicle accident trauma to the cranium, mostly found in the paranasal region. All trauma

is found in males, except for one female, which suggests some form of sex-specific

(intramale?) aggression is taking place. Of the 11 males, 5 injuries are found on the left

side and 9 are on the right. The female exhibits a perimortem linear fracture to the left

temporal extending into the left parietal. Her cause of death is noted generically as a

'brain hemorrhage' on the death certificate, so it is possible that this injury was due to a

motor vehicle accident or it could be a fracture (contra coup?) from blunt force trauma of

unknown mechanism. She does not display any additional skeletal trauma except for a

perimortem compaction-type fracture to the distal epiphysis of the left ulna.

As seen in Table 7-7, rib fractures are frequently encountered in this sample. No

significant preference for side or exact region on the rib can be discerned. Several

individuals have multiple rib fractures in different stages of healing, which might suggest

aggression. However, the lack of concomitant craniofacial trauma, as well as the

osteoporotic state of the majority of skeletons, suggests either accidental (fall, motor

vehicle accident) or underlying pathological origins (cancer-related osteoporosis) of the

fractures.

No skeletal indications of overtly intentional violence (i.e., parry fractures or lethal

sharp force/blunt force/projectile trauma) are found in this collection. Nor is there any

indication of chronic physical abuse such as multiple fractures in various stages of

healing outside of the above mentioned rib fractures.

Diet and health

Low socioeconomic status also generally precludes access to adequate diet and

health care. Evidence of poor nutrition such as chronic anemia caused by iron deficiency









in the diet can be seen osteologically as perpendicular orientation and expansion of the

trabeculae in the cranial diploe, thinning of the compact cranial bone (porotic

hyperostosis) and thickening of the orbital roof (cribra orbitalia). These lesions result

from hypertrophy of the blood-forming tissues in the marrow in order to increase the

production of red blood cells in response to the anemia. The increase in marrow

production results in the replacement of the outer table of compact bone with exposed

diploic bone, which gives the appearance of raised and porous zones of skeletal tissue

usually on the cranial vault and/or orbits (Stuart-Macadam 1987). A variety of

nondietary or genetic factors may also cause iron deficiency including thalassemia, sickle

cell anemia, traumatic blood loss, parasitic infection and chronic diarrhea (Stuart-

Macadam 1989).

Only three individuals (1 male, 2 females) in the UA sample display cranial vault

porotic hyperostosis, while 5 individuals (3 males, 2 females) have cribra orbitalia in

various stages of activity and healing at death. As age and cause of death range widely

among those affected, no particular pattern is discerned regarding underlying diet,

behavior or disease.

Health Care Funding

Funding is a perpetual problem in the development and improvement of Greek

medical care. National funding cuts resulted in a decrease in the total number of hospital

units in all of Greece from 595 in 1984 to 341 in 1998 (Greece in Figures 2003, National

Statistical Service of Greece). Financial roadblocks also affect research. Indeed,

attempts to organize a basic trauma registry at a teaching hospital in Crete were met with

both financial setbacks as well as general lack of enthusiastic participation from

overworked hospital staff (Sanidas et al. 2000). Additionally, a recent study out of a









hospital in Piraeus found that an alarming 42% of all DOAs could possibly have been

prevented if pre-hospital emergency medical care had received funding for basic

technological upgrading (Papadopoulos et al. 1996).

There are 201 health centers situated in Greek rural and semi-urban areas

(Theodorou 2003). These facilities are administratively linked to large urban health

centers and are mostly staffed by recent medical graduates, who are required to spend one

year of service in a rural area upon graduation. Limited human and financial resources,

organizational problems and a lack of clinical experience by doctors raises concerns

about the quality of service delivered at satellite health centers. Although it is not known

for certain, some of the injuries found in the UA collection may have occurred outside of

greater Athens in rural areas lacking optimum health care. This collection in particular is

composed of those less wealthy citizens who for the most part could not afford permanent

placement in the mausoleums of the Zografou Cemetery in Athens. The following

highlights trauma found on some of the individuals.

Figure 7-2 illustrates a well-healed fracture to the distal left radius in a 59-year-old

female. During a fall onto an outstretched pronated arm, the dorsal surface of the arm is

placed under compression while the ventral surface is under tension. The tensile forces

cause a transverse fracture and there is a subsequent crumbling of the posterior (and

sometimes carpal) surface. These fractures tend to result most often from low energy

trauma such as a fall from a standing height (Galloway 1999). The carpal articular

surface of this individual is comminuted and the afflicted radius is 13 mm shorter than

the contralateral element. There is a 5-degree dorsal angulation. No evidence of internal

or external fixation (i.e., implanted hardware, resorbed drill tunnels) is seen.









Residual deformity from a poorly treated radial fracture may have subsequent

effects on wrist movement due to the precise geometry of the wrist joint. Loading

patterns across the wrist are affected by very minor changes in distal radial geometry as

little as 2.5 mm of radial shortening significantly shifts force loading to the distal ulna.

This disturbs the relationships and the forces at the distal radioulnar joint, which

manifests as pain and limitation in forearm rotation (Cohen et al. 2003). Although the

injury to this specific individual healed very well without surgical intervention, it is

surprising that open reduction was not pursued.

Alffram & Bauer (1962) found that in older women, distal forearm fractures occur

more often with simultaneous fractures of the proximal end of the femur, as might be

seen in falls from a standing height. Of the 12 radii with distal fractures and the 11

proximal femora with fractures in the UA sample, only 3 individuals have fractures to

both sites. Two of the individuals are elderly males and the other is an elderly female.













Figure 7-2. Fractured distal left radius (left) and normal contralateral right radius (right),
carpal view

Figure 7-3 shows another fractured left distal radius, this one in a 73-year-old

female. There is marked dorsal angulation and 9 mm shortening of the afflicted. Again,

there is no evidence of open reduction.



















Figure 7-3. Fractured distal left radius (left) and normal contralateral radius (right),
lateral view

Figure 7-4 shows a fractured right proximal femur in an 81-year-old male. Post-

operatively, the femoral neck retains noticeable posterior angulation with 16 mm

shortening of the afflicted element. There is marked resorption around the neck

component of the appliance. Poor appliance placement on the diaphysis resulted in

minimal investment of the cortical screws. Such placement results in a biomechanically

disadvantage femur where axial loads are not fully supported during healing.













(a) (b) (c)
Figure 7-4. Fractured right proximal femur: (a) posterior, (b) posterior-lateral close-up
of appliance and (c) posterior close-up of cortical screw in diaphysis

Figure 7-5 shows a complication of flexible orthopaedic appliances (Ender nails)

used to internally fix a fractured greater trochanter and neck of the right femur in a 78-

year-old male. Either excessive force during insertion or inappropriate post-operative









axial loading by the patient resulted in the nails bursting through the distal anterior femur

superior to the condyles.















Figure 7-5. Orthopaedic fixation in a fractured greater trochanter and neck of the right
femur, anterior view

Figure 7-6 shows a fractured neck and proximal diaphysis of the right femur in an

85-year-old male. The neck component of the orthopaedic appliance is poorly aligned;

threads are seen exposing from the cortex of the neck. The femoral head is angled

anterior and marked reactive bone embedding the appliance suggests inappropriate post-

operative movement of the fractured ends.


(a) (b) (c)
Figure 7-6. Fractured neck and proximal diaphysis of the right femur: (a) anterior, (b)
posterior and (c) posterior close-up









Osteoporosis and Fractures

Compared with North American, Finnish and German populations, both Greek men

and women have consistently lower bone mineral density (BMD) in the decades over 40

years. In a study on BMD of the vertebrae, proximal femora and calcaneii in normal

Greeks, Hadjidakis et al. (1997) found that the total bone loss between ages 20 and 70 is

29.5% for the vertebrae and 32% for the femoral neck in women, whereas the values for

men are 19.5% and 29% respectively. Hip fractures, the most dramatic complication of

osteoporosis, has shown an average annual increase of 7.6% in Greeks from 1977-1992,

due partly to an aging demographic (Paspati et al. 1998). While not clinically measured,

the majority of individuals in the UA sample are to some degree osteoporotic. Fragile,

lightweight bones are seen especially in the females, but also in many of the males. The

advanced age of the average individual comprising the sample, as well as the high

prevalence of cancer and other chronic illnesses among the group, likely contribute to

frequently osteoporotic skeletons.

Research Question 2: Do the Specific Geographical and Population Characteristics
of Athens Result in Increased Trauma in the UA Sample?

Bioarchaeological research has highlighted the importance of various geographical

and population factors on trauma occurrence. Using a prehistoric Indian sample from the

Channel Island area of southern California, Walker (1989) demonstrated the influence of

resource competition stress in the geographically circumscribed area on skeletal trauma

frequencies. High population density and social stress brought on by resource

competition and land scarcities are likewise blamed for elevated craniofacial trauma

found in preceramic northern Chilean coastal communities (Standen & Arriaza 2000) and

Sudanese Nubians (Alvrus 1999).









Bioarchaeological studies have associated certain geographical features with

elevated skeletal injuries. The uneven geophysical terrain of Nubia is suggested as the

particular cause of elevated accidental appendicular fracture frequencies found at the

neighboring sites of Semna South (Alvrus 1999) and Kulubnarti (Kilgore et al. 1997).

Both sites are in the Batn el Hajar region just south of the Egyptian border an area

characterized by a dry and boulder-strewn landscape.

Geography

Greece is surrounded by water on three sides: the Ionian Sea to the west, the

Aegean Sea to the east and the Mediterranean Sea to the south. These adjoining seas are

studded with thousands of rocky islands, of which only 200 or so are habitable. Three-

fourths of Greece's terrain is rocky with little or no significant topsoil (U.S. Dept. of

State Post Report 2003).

Athens is located in the southeastern aspect of the Attican Peninsula of the Greek

mainland. It is the largest city of the country and with an estimated 3,700,000

inhabitants, is home to 40% of the Greek population (U.S. Dept. of State Post Report

2003). The city itself is geographically enclosed by the Parnis, Pendeli and Hymettos

mountain ranges on three sides. The Gulf of Saronikos the inlet of the Aegean Sea -

provides the fourth border.

Population

The current population density of Greece is 80 individuals per km2. The city of

Athens, however, has a population density of 923 individuals per km2, with 60% of the

entire Greek population living in an urban setting (UNECE Trends in Europe and North

America 2003).









As in many countries in Europe, the total fertility rate of Greece is nearly below

replacement value. As a result, the rate of natural increase in Greece's population as a

whole has shown a slow growth of only about 0.06% per year, due mostly to immigrants

from Albania, the Former Yugoslav Republic of Macedonia and the Russian Federation

(WHO Highlights on Health in Greece 1998). Greater Athens, however, has undergone

significant recent population surging, with numbers increasing almost two-fold in the last

three decades due to an influx of foreign immigrants and rural Greeks into the capital

pursuing economic opportunity (Table 7-11). Growth within the country as well as in the

capital are physically constrained within naturally limiting geographical boundaries

compounded by mountainous and uneven terrain.

Table 7-11. Total population increases for Greece and greater Athens for select
decades
1971 1981 1991 2001
Greece 8,894,981 9,667,336 10,134,534 10,206,539
Athens 1,985,221 2,276,750 2,519,661 3,700,000*
*2004 estimate. Compiled from Greece in Figures 2003, National Statistical Service
of Greece.

Despite a high unemployment rate, Greeks continue to make significant purchases

such as automobiles, which are unfortunately a necessity in the city due to limited mass

transportation. Over one million registered vehicles clogged the streets of Athens in 2003

(U.S. Dept. of State Post Report 2003). Given the geographic constriction of the city, this

increase in road traffic has led to a subsequent increase in motor vehicle accident (MVA)

fatalities. Indeed, Greece is currently the third highest for MVAs among all European

Union countries (Kardara & Kondakis 1997).

Four individuals in the UA collection display obvious perimortem high impact

trauma caused by vehicular accidents (it is not noted on the death certificates whether the









individual was a vehicle occupant or pedestrian). Skeletal trauma on these individuals

includes multiple craniofacial and postcranial fractures. Figure 7-7 shows craniofacial

injuries sustained by a 43-year-old male in a motor vehicle accident.

Figure 7-8 shows a 34-year-old male who sustained multiple fractures from some

type of (vehicular?) impact mainly to the left side of the body. The left tibia has an

oblique fracture to the proximal diaphysis. The afflicted element has 26 mm shortening,

90% apposition and lateral displacement of the proximal segment. The ipsilateral fibula

has a transverse fracture to the proximal 14 of the diaphysis, 5 mm shortening, 90%

apposition and anterior displacement of the proximal segment.















(a) (b)
Figure 7-7. Craniofacial trauma caused by a motor vehicle accident in a 43-year-old
male: (a) trauma to the right frontal bone including medial orbital elements
and (b) close-up of the right orbital area. The sclerotic callus and healed
fracture in the right superior orbit lateral to the perimortem injury are
evidence of a previous traumatic episode.






















(a) (b)
Figure 7-8. Tibial fracture in a 34-year-old male: (a) left tibia, anterior view and (b) left
tibia, posterior view

Despite ecogeographical constraints, high unemployment rates, focalized resources

competition and a high urban population density, non-motor vehicle accidents and other

violent mortality rates in Greece are among the lowest in EU countries and are also well

below the United States (Table 7-12). Certainly, skeletal injury in the UA sample seems

to be overwhelmingly non-violent in origin.




Table 7-12. The 1997 death rates per 100,000 population for males/females, Greece and
the United States
Greece U.S.
Males Females Males Females
MVAs 34.3 10.4 21.3 10.6
Accidental falls 4.5 2.7 5.9 5.7
Suicide 6.2 1.0 18.7 4.4
Homicide 2.6 0.6 13.8 3.9
WHO Annual Statistics. Table 1: Numbers of death and death rates. Greece, 1997, and
United States of America, 1997.

Nineteen individuals (15.7%) in the UA collection sustained trauma to the forearm

and/or hand. Of these, 15 involved the distal radius, mainly taking the form of Colles',

Smith's and radial styloid fractures. Two scaphoid fractures are also found. The









locations of these injuries are suggestive of falls on outstretched hands. Distribution of

the injuries is spread evenly between males and females with an average age of 70 years.

The rocky and uneven terrain of Greece, as well as the osteoporotic state of the majority

of these aged individuals, possibly led to this relatively high frequency of wrist injuries.

Seven individuals (5.8%) have trauma to the distal tibia, fibula or calcaneus that are

suggestive of ankle-twisting injuries or falls. Fractures to the distal diaphysis of the tibia,

medial malleolus, fibular styloid process, and talar surface of the calcaneus are the most

common ankle injuries in the collection. As with the wrist injuries, the distribution of

ankle injuries is spread evenly among males and females. The average age of those with

ankle injuries is 69 years. Injuries in these ankle locations reflects accidental trauma,

probably while traversing uneven ground.

Does the Age Bias of the Individuals in the UA Sample Result in Increased Skeletal
Trauma?

The average life expectancy for Greek males and females in 2002 was 75.8 and

81.1 years, respectively (World Health Organization 2003). Greek life expectancy

continues to be one of the highest in the EU community and also surpasses the average

for the United States, even though Americans spend approximately 13% of their annual

income of health compared to 8.4% by Greeks (see Table 7-13).

Table 7-13. Life expectancy at birth for males/females: Greece, neighboring
Mediterranean countries and the United States
Country Life expectancy in years
Males Females
Greece 75.8 81.1
Italy 76.8 82.5
Cyprus 75.5 79.1
Turkey 67.9 72.2
U.S. 74.6 79.8
WHO Annex Table 1: Basic indicators for all member states, 2002.










There has been a considerable change, however, in the population structure of

Greece; the number of people aged 65 years and over has increased from 11% to 15%,

while the percentage of the population aged less than 15 years has decreased from 25% to

17% (WHO Highlights on Health in Greece 1998). Low fertility, increased longevity and

emigration of young adults from Greece for education and employment opportunities

elsewhere have led to an aging of the population. Figure 7-9 displays this trend in the

Greek population for the decade 1990-2000.

Assuming that as one ages, one is chronologically exposed to more opportunities

for traumatic episodes, the advanced age of many of the individuals in the UA collection

should result in increased cumulative antemortem injuries. The Pearson r test for

association between age and the total number of injuries per individual resulted in a slight

positive correlation (r = .169). Thus, as age increases, so does total number of injuries.


3000000

2500000

S2000000 -

S1500000

S1000000
F- -1990
500000 1990
--2000
0
0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
Age category

Figure 7-9. Age category frequencies for all Greeks, 1990 and 2000. Compiled from:
UNECE Trends in Europe and North America. The Statistical Yearbook of
the Economic Commission for Europe 2003.









Biological Variables Associated with Skeletal Trauma

Known biological variables for the UA collection include sex and age at death.

Crosstabulations were computed for sex and general trauma location in order to

determine if any significant relationship between the two variables. To facilitate analysis,

all skeletal trauma was compiled into categories based on location. The categories

include: face, head, rib/sternum, vertebrae, shoulder girdle, humerus, arm/hand, pelvic

girdle, femur and leg/foot. Significance relationships exist between sex face (X2

12.536, p=.00) and sex vertebrae (2 12.969, p=.00), with males having significantly

more trauma in these two locations than females. No relationship was detected between

sex and any other location.

Chi-square tests for independence were conducted on age and the same general

trauma locations described above. Numerical age for each individual was first

categorized into one of eight categories: 1 (21-30), 2 (31-40), 3 (41-50), 4 (51-60), 5 (61-

70), 6 (71-80), 7 (81-90) and 8 (91-100). No significance was found. Age categories

were then compressed to include just three categories: 1 (21-40), 2 (41-60) and 3 (61-

99). Still no significant associations were found.

Signifance testing was also performed to determine if males experienced more

cumulative trauma than females. While there is a difference in the frequency of multiple

trauma by sex (average 1.5 injuries per male, 1.9 per female), a one-way ANOVA test

proved it not significant (p=. 115).

Population-Specific Evidence of Accidental Versus Intentional Injury

The study of interpersonal violence as inferred from the skeleton is highly

intriguing to both scholars and the lay public. However fascinating it is to read such sexy









reports, osteologists often have difficulty determining if trauma observed on an individual

skeleton is the result of accidental or intentional mechanisms in the absence of associated

weaponry. Certain types of trauma, such as parry fractures to the ulna and cranial pond

fractures, are often cited as proof positive that intentionally violent encounters occurred

(Wells 1964), although the true causal behavioral link suggested is unknown.

Keeping these factors in mind, one can still carefully attempt to examine patterns of

skeletal trauma, with the hope that causal mechanism will be illuminated. Such an

analysis must take into consideration all known demographic and cultural variables of the

collection. For example, age and sex are important dimensions of the modern violence

pattern in that various cultural factors may make one sex or age group more vulnerable to

aggression than another. Modern assault victims show a distinctive distribution of

skeletal injuries with high facial trauma rates, especially in cases of abuse to females.

The upper limb is typically the next most common injury site. Novak (1999) found that

tandem craniofacial and thoracic injuries suggest aggression, while solo appendicular

injuries suggest accidental mechanisms.

To test for possible relationships between the coexistence of craniofacial, thoracic

and appendicular injuries in the UA sample, loglinear modeling was applied using SPSS

Advanced Models 12.0. The loglinear technique models the means of cell counts in

multi-dimensional contingency tables by describing the association patterns among a set

of categorical variables without specifying any variable as a response (dependent)

variable. It is structured to fit hierarchical linear models to crosstabulations using

iterative proportional-fitting algorithms (SPSS Advanced Models 12.0). These

techniques allow the analysis of chi-square-type data using regression-like models. They









are essentially multiple linear regression models in which the classification variable and

their interaction terms are the independent (predictor) variables, and the dependent

variable is the natural logarithm of the frequency of cases in a cell of the frequency table.

Using the natural log of the frequencies produces a linear model.

Loglinear analysis focuses on studying associations between pairs of variables

rather than modeling the response on one of them in terms of the others. The loglinear

model formulae express the logs of cell expected frequencies in terms of dummy

variables for the categorical variables and interactions between those variables (Agresti &

Finlay 1997). Thus, all variables in the multi-dimensional contingency table used in

loglinear models are response variables, rather than one a response and the others

explanatory. The resulting model describes associations in partial tables that relate, for

example, two of the variables while controlling for the third one.

The term loglinear comes from the form of the model; the natural logarithm of cell

counts is modeled as a linear function of the effects of categorical variables and their

relationships. For example, to investigate relationships between three categorical

variables X, Y and Z, the full (saturated) loglinear model is:

log(m) = t + kX + X v + Y z + kXY + kXZ + kYZ + kXYZ

where: kx, kv and kz represent the 1st order main effects of the independent variables
iXY, Xxz and vYz represent the 2nd order interactive effects
XXYZ represents the 3rd order interactive effect of all variables X, Y and Z

In the saturated model, all terms correspond to all possible main effects and interactions,

and thus the model fits the data perfectly. This does not provide any information

regarding the effects of any variable or possible interactions of variables, so one then

estimates a non-saturated model containing a subset of the parameters from the saturated









model and tests the difference between that and the saturated version. Such tests are

called "goodness of fit" tests, because they tell whether the model in question is

significantly worse than the saturated, or perfect, model. The likelihood ratio best tests

the goodness of fit. If the reduced model is true, the likelihood ratio statistic has a

distribution that approaches a chi-square distribution as the sample size increases.

To preserve statistical power, there need to be at least 5 times the number of cases

as cells in the data. For example, for a 2 x 2 x 3 contingency table, one needs to have at

least 60 cases. If the required amount of cases is not met, then the sample size needs to

be increased, the number of variable categories needs to be compressed or variables need

to be eliminated.

To perform loglinear modeling on the UA data, trauma locations were first

organized into six skeletal loci: craniofacial, thoracic, proximal upper appendicular,

distal upper appendicular, proximal lower appendicular and distal lower appendicular.

Table 7-14 defines the elements of each locus. The resultant contingency table contained

an excessive number of cells with less than the minimum of five counts, so the loci were

compressed to include craniofacial, thoracic and a broader appendicular category

including all elements in the previous last four loci.

Table 7-14. Loci used in the loglinear model and their respective skeletal elements
Locus Includes
Craniofacial all facial, cranial, and mandibular elements
Thoracic ribs, vertebrae, sternum
Proximal upper appendicular clavicle, scapula, humerus
Distal upper appendicular radius, ulna, carpals, metacarpals, phalanges
Proximal lower appendicular innominates, femur
Distal lower appendicular patella, tibia, fibula, tarsals, metatarsals, phalanges

Likelihood ratio output from loglinear testing of a hierarchical model compared to

the saturated model indicated no significance at the 1st' 2nd or 3rd order levels (p>.05). To









test the individual 1st order effects within themselves, crosstabulations and chi-square

tests for independence between the pairs craniofacial thoracic, craniofacial *

appendicular and thoracic appendicular were conducted. All tests resulted in non-

significant results at the .05 level (p=.217, .711, .104 respectively).

To further test for association between the categorical variables, odds and odds

ratios were computed for 2 x 2 tables cross classifying craniofacial thoracic and

craniofacial appendicular loci (Table 7-15). Since the odds ratio treats variables

symmetrically, it does not require identifying a response variable. This makes the odds

ratio a natural measure when there is no obvious distinction between the variables, such

as when they are both response variables (Agresti & Finlay 1997).

For individuals with craniofacial trauma, there are 2.14 (15/7) individuals with

concomitant thoracic trauma for every one individual without thoracic trauma. For

individuals without craniofacial trauma, the odds of having thoracic trauma equal 1.16

(51/44). This means that there are 1.16 individuals with thoracic trauma for every one

individual without thoracic trauma. For individuals with craniofacial trauma, the odds of

having concomitant thoracic trauma are 1.84 (2.14/1.16) times the odds of having

thoracic trauma without concomitant craniofacial trauma.

Table 7-15. Cross-classification of craniofacial, thoracic and appendicular trauma in the
UA sample
Thoracic Appendicular
Craniofacial Yes No Total Craniofacial Yes No Total
Yes 15 7 22 Yes 13 9 22
No 51 44 95 No 52 43 95


For individuals with craniofacial trauma, there are 1.44 (13/9) individuals with

concomitant appendicular trauma for every one individual without. For individuals









without craniofacial trauma, the odds of having appendicular trauma equals 1.21. This

means that there are 1.21 individuals with appendicular trauma for every one individual

without. For individuals with craniofacial trauma, the odds of having concomitant

appendicular trauma are 1.19 (1.44/1.21) times the odds of having appendicular trauma

without concomitant craniofacial trauma.

Put in simpler terms, these cross-classifications indicate that individuals with

craniofacial trauma also tend to sustain trauma in both the thoracic and appendicular

trauma. Also, individuals are somewhat more likely to display craniofacial and thoracic

trauma together than they would craniofacial and appendicular.

Another method to determine possible patterns in the coexistence of trauma at

different skeletal loci is to construct a 3-dimensional contingency table. Table 7-16 lists

the general location of skeletal trauma on all individuals in the UA collection. Each

location (craniofacial, thoracic and appendicular) has one of two possible responses (yes

or no).

Table 7-16. Three-dimensional contingency table using the UA data
Craniofacial Thoracic Appendicular % yes
Yes No
Yes Yes 9 6 60.0
No 4 3 57.1
No Yes 31 19 62.0
No 20 24 45.4

From this table, the following statements can be made: (1) for individuals with

craniofacial trauma, appendicular trauma was seen 60% of the time when thoracic trauma

was also present and 57% of the time when thoracic trauma was not also present, (2) for

individuals without craniofacial trauma, appendicular trauma was seen 62% of the time

when thoracic trauma was present and 45% of the time when thoracic trauma was not









present, (3) for individuals without craniofacial trauma, appendicular trauma was seen

16.6% (62.0-45.4) more often when thoracic trauma was present that when it was absent

and (4) controlling for craniofacial trauma (by keeping it fixed), the percentage of

appendicular trauma is higher when thoracic trauma is also present.

While no obvious population-specific pattern of intentional versus aggressive

injury is found, these findings further underscore the importance of considering the entire

skeleton in trauma analysis when it is available. Lastly, although the UA sample does not

exhibit evidence of large-scale interpersonal aggression, the prevalence of craniofacial

injury in the group is modestly high (10.7%). The fact that 12 of the 13 individuals

(92.3%) are male suggests some type of cultural factor is involved with the frequency of

trauma to this area.

Occupation, Cause of Death and Sex

Crosstabulations were performed to test for possible relationships between

occupation and cause of death. After all cells with <5 were omitted (thus including only

the domestic and private sector employee categories for occupation and unknown, cardiac

and cancer categories for cause of death), no association was found between any

occupation or cause of death category (p=.611).

Similar crosstabulations were performed to test for possible relationships between

sex and cause of death category. After all cells with <5 omitted in the cause of death

categories (thus only including cardiac and cancer), significance is found between the

two variables (p=.04). A possible association exists, then, between sex and cause of

death such that females succumb more often to cardiac illness and males succumb more

often to cancer.









Comparison to Archaeological Samples

Trauma frequencies of the UA sample were compared to geographically similar

archaeological collections. Table 3-1 compiles skeletal analyses of various Greek and

Mediterranean sites published by J. Lawrence Angel. Several important caveats must be

taken into consideration when examining this table. As previously discussed, skeletal

trauma was not the focus of Angel's work. Rather, he was primarily interested in tracing

Greek social biology through cranial morphometrics (Angel 1944, 1946). He did,

however, attempt to document traumatic and pathological conditions found on certain

individuals. When Angel gave information on whether injuries were found in males or

females, it is indicated in the table. Blank cells do not necessarily mean that injuries were

absent in many of his reports, postcranial trauma was not discussed at all. Actual

cranial and postcranial trauma occurrences are likely higher than reported, as the

archaeological materials Angel analyzed were usually highly fragmented.

Archaeologically, fractures to the distal extremities are suggestive of consistent

interaction with the rough, sloping and mountainous terrain characteristic of Greece.

Indeed, the prevalence of postural indicators (i.e., squatting facets, Allen's fossae) and

the degree of muscular development noted among the individuals noted by Angel (and

discussed in Chapter 3) supports this assumption. There is also a relatively high

frequency of male cranial trauma suggesting elevated cultural stressors such as

interpersonal (intramale) aggression, internecine warfare, and probable defense of the

community against warring invaders.

As with the ancient samples, numerous individuals in the contemporary UA

collection display reactive areas on the femora called anterior cervical imprints, or

Allen's fossae (Capasso et al. 1999). This facet is found on the anterior aspect of the









medical femoral neck and is due to hyperextension of the femur and rotation of the head

in the acetabulum, usually from downhill walking or traversing mountainous landscapes

(Figure 7-10). The zona orbicularis normally resists hyperextension of the femur by

tightening around the femoral neck. The fossa forms where the zona bifurcates around

the iliofemoral ligament.












Figure 7-10. Left femur from the UA sample with Allen's fossa located inferior to the
anterior articular surface of the femoral head

The prevalence of male cranial trauma over female cranial trauma is also found in

the contemporary UA sample. Some type of cultural factor is causing elevated

frequencies of craniofacial injury in Greek males. Angel's warfare proposal makes sense

given the temporal and geographic nature of his ancient samples. Contemporary Greek

males, however, are not in the same political position as their ancient forefathers. This

sample in particular, while rather aged, is not of the correct demographic to have

participated in any large-scale political upheavals or warfare. Given the lack of other

credible reasons for frequent male cranial injuries, one is left with two possible scenarios:

(1) males are simply more physically active than females and therefore expose

themselves to more opportunities for accidents or (2) males are engaging in some type of

interpersonal (probably intramale) aggression.









The UA collection also contains more individuals with wrist and ankle injuries than

in Angel's ancient samples. As individuals from both the ancient and contemporary

groups were exposed to identical geography, it makes sense that both would exhibit

similar accidental trauma patterns to some degree. A likely reason why Angel's samples

show less appendicular trauma is due to the fact that he simply was not as concerned with

postcranial trauma as he was obvious craniofacial injuries and skeletal morphology.

Table 7-17. Research questions examined in this study and their results.
Question Result
Does deprived socioeconomic No evidence of increased trauma, assault
status result in increased trauma, or abuse, but poorly treated fractures are
assault and abuse, medical care? common


Do limiting geography,
environmental circumscription
and increased population density
result in increased trauma?

Does advanced age result in
increased trauma?

Which biological variables are
most associated with skeletal
trauma?

Is there population-specific
evidence of accidental vs.
intentional injury?

What is the relationship between
occupation and cause of death?

What is the relationship between
sex and cause of death?


Comparison to archaeological
samples


Increased distal appendicular injuries, but
increased population density does not
necessarily lead to increased overall
trauma

Yes


Increased facial and vertebral trauma in
males


No. Concomitant trauma (craniofacial,
thoracic and appendicular) is more likely
than singular craniofacial trauma

None


Females die more frequently from cardiac
disease while males die more frequently
from cancer


Similar male craniofacial trauma
dominance and increased distal
appendicular trauma














CHAPTER 8
DISCUSSION

Summary of findings

Morphological analysis of a sample (n=121) of individuals from the University of

Athens skeletal material suggests that the majority of skeletal trauma is the result of

cumulative accidental episodes. Injuries observed show no distinct constellations

suggesting intentional, interpersonal violence. Significant trauma clustering is seen in the

thoracic vertebrae, ribs, radii and femora. These fracture loci are typical in an aged,

osteoporotic population. Crosstabulations, ANOVA and loglinear analysis show

associations between sex and trauma location, sex and cause of death category and some

degree of association between concomitant trauma locations. No statistical relationship is

found between age and trauma location.

Despite what is suggested in the bioarchaeological and clinical literature, the

presumed relatively low socioeconomic status of the individuals in the UA collection did

not result in increased skeletal trauma. Crime rates, violent mortality, and homicide and

suicide rates in Greece continue to be among the very lowest in the European Union and

well below rates in the United States. Only 9.9% of the individuals sustained non-motor

vehicle accident craniofacial trauma, a surprisingly low frequency given the significant

social and economic stresses this population is under. Only 2.5% exhibited active or

healed porotic hyperostosis and/or cribra orbitalia at death, the majority of which are

likely due to chronic diseases associated with death rather than any dietary deficiencies.

There is no evidence of overtly intentional trauma.









Injuries from traversing the treacherous terrain of Greece are found in the ankle and

foot area of 16% of the sample. Some 6% of the sample shows skeletal injury of the

forearm and/or hands, probably the result of falls. Population surging and environmental

circumscription have led to increasing trauma from motor vehicle accidents.

The UA collection seems to mirror that of the overall contemporary Greek

population by representing a subset of a modern, relatively nonviolent society. Despite

ecogeographical constraints, high unemployment rates, focalized resource competition

and a surging urban population, violent mortality rates in Greece are among the lowest

globally. Thus, contrary to socioeconomic stress theories suggested in the

bioarchaeological and clinical literature (Harries 1997; Cubbin et al. 2000a; 2000b;

Faelker 2000; Lyons et al. 2000; Wagner et al. 2000; Hasselberg et al. 2001; Blakely et

al. 2002), contemporary Greeks do not show increases in trauma from assault, abuse and

other violent crimes due to economic and populational stressors.

Diet and Disease

A Mediterranean diet high in natural oils, fish and vegetables has been shown to

improve longevity, especially coronary disease related mortality (Trichopoulou et al.

2003). Indeed, factors that most influence a significant reduction in coronary events

globally include physical activity, high levels of education and adherence to a traditional

Mediterranean diet (Panagiotakos et al. 2002). Several emerging lifestyle risk factors

among Greeks, however, such as increasing mental depression, smoking and adopting a

less healthful (fast food) diet have contributed to the steady increase in death rates from

coronary and chronic respiratory disease seen beginning in the 1960s (Chimonas 2001;

Karakatsani et al. 2003). The eradication of malaria, rheumatic fever, decrease in

infectious diseases, improvement of medical care system and the rise of the populations'









socioeconomic level during the last 5 decades in Greece have reduced all-cause mortality

(Chimonas 2001). Statistically, Greece remains the country with the lowest death rates

from coronary heart disease among major European countries (Menotti et al. 1999) and

with reference to total cancer mortality, Greeks have the lowest rates in the European

Union (Black et al. 1997; Levi et al. 1999).

As the UA sample is biased toward the elderly, perhaps the advanced age cohort

refrained more from the newer fast foods and kept to a healthier traditional

Mediterranean diet. Even so, chronic cardiac- and cancer-related illnesses are the leading

causes of death among all individuals in the UA collection but are especially common in

those individuals of advanced years.

Regarding macroscopic skeletal evidence of dietary distress or nutrition among

individuals in the UA collection, only three individuals (1 male, 2 females) display

cranial vault porotic hyperostosis, while 5 individuals (3 males, 2 females) have cribra

orbitalia in various stages of activity and healing at death. As age and cause of death

range widely among those affected, no particular pattern is discerned regarding

underlying diet, behavior or disease.

Substance Abuse

Greece has recently experienced an increase in drug and alcohol abuse as well as

drug related illegal behavior. Kokkevi and colleagues (1993) found male gender,

polydrug use, unemployment and low education level to be among the main factors

significantly predicting criminality of drug abusers in Greece.

It is important to consider the sociocultural context of substance use in the Greek

population. Especially among students, substance abuse has traditionally been

understood differently from that of many other European and North American countries.









Greece is a tobacco and alcohol producing country and there are no restrictions

whatsoever on their sales. This, in conjunction with the fact that they are both socially

accepted substances, explains their widespread use among the Greek population. While

the percentage of frequent alcohol consumers in Greece is among the highest in Europe,

the majority of the youth tend to drink only occasionally.

Among students, cannabis, regular tobacco and illicit drug use have shown sharp

increases during the 1990s while alcohol and unprescribed psychoactive medicines have

decreased (Kokkevi et al. 2000). So, while Greece is no longer among the low

prevalence European countries in illicit drug use, it still remains at much lower levels

than the United States.

Only one individual in the UA collection reportedly died of a known drug

overdose. However, the advanced age of the majority of individuals likely produces a

lower than expected prevalence of drug abuse as this age cohort probably did not engage

in such risk taking behaviors as much as younger individuals.

Child Abuse and Other Interpersonal Violence

Greece's recent transition from a traditional to an industrialized society has resulted

in cascading effects in Greek culture. The primary unit of change has involved the family

structure, where a gradual shift is observed in organization from collectivism to

individualism. The large, traditional extended family is beginning to change into a more

contemporary, nuclear unit with young family members often leaving the home and

country for economic pursuits elsewhere. These changes bring with it a number of high

risk factors at the individual, family, community and social levels concerning violence

due to social stressors. While still relatively low compared to other European countries,

Greece is just beginning to experience violent crime rates slightly above prevalence rates









in the previous decades. Petridou and colleagues (2001) found that an average of 0.23%

of all Greek children presenting at hospital emergency departments have injuries

attributed to acts of violence. These injuries are more common among migrant children

who are faced with their own suite of social, cultural and economic hurdles.

As in other areas of violence, income and education seem to be the most influential

factors associated with child abuse, where the mother's level of education mostly affects

the level of prenatal/perinatal care, infant mortality rate and the infant's future growth

and health care (Kafatos et al. 1978). Agathonos-Georgopoulou & Browne (1997) found

other high risk predictors to include a child's poor state of hygiene upon presentation to

the emergency ward, parents with mental health problems, poor relationship between

parents, parents with adverse life experiences and a mother strictly disciplined by her

own parents.

No subadults in the UA collection bear skeletal evidence of abuse. The fact that

there are only three subadults in the entire sample should be taken into consideration,

however. There is also no skeletal evidence of abuse to the elderly.

No population-specific data on skeletal manifestations of interpersonal violence

among contemporary Greeks is presented here due mainly to the limited sample size

upon which such standards would be drawn. Assuming the data were adequate, a general

overview of the collection shows no patterns of trauma suggesting either accidental or

intentional mechanism. The nature of this essentially non-forensic collection an aged

population with mostly naturally occurring deaths precludes assessment of

interpersonal trauma patterns. Males in the collection do have significantly more facial

trauma than females (22% and 2%, respectively). Whether males are engaging more in









interpersonal aggression or are sustaining such injuries due to more physically active

interaction with the environment is unknown.

Suggestions For Further Research

Skeletal analyses on future remains received from the Zografou ossuary in Athens

will be helpful in better answering the hypotheses and questions proposed. It would be

very helpful to amass more detailed demographic information including the length of

time individuals actually resided in Athens (were they long term residents or recently

transported there for medical care?). It would also be helpful to attain supporting medical

documents in order to discover both the actual cause and manner of death. Any skeletal

fracture details included in the hospital documentation could be used to perform

postmortem analyses of fracture repair technique and outcome. If postmortem

radiographic studies could be performed, fracture-healing rates could be measured.

Metric evaluation of the long bone diaphysis might provide information on any

correlation between diaphyseal length and fracture occurrence. Lastly, three-dimensional

digitization of the crania and postcrania could assist with the development of population-

specific identification protocols.















APPENDIX A
ZOGRAFOU CEMETERY AND MAUSOLEUM, ATHENS


Figure A-1.


Primary burials maintained in Zografou Cemetery, looking northwest.
Photo by the author.


Figure A-2. Extreme eastern perimeter of Zografou Cemetery. A maintenance facility is
seen in the background. Photo by the author.







81














r~-














Figure A-3. One of two communal subterranean bone vaults on the southern perimeter of
Zografou Cemetery. Religious icons, incense containers and photographs of
deceased individuals are in the foreground. A skeletonized body still
wrapped in its burial shroud can be seen within the vault. Photo by the
author.


Figure A-4. Close-up of a subterranean vault. Photo by the author.






























Figure A-5. Interior of the Zografou Cemetery Mausoleum. After exhumation, most
individuals are secured in metal boxes and placed on shelves in this facility,
where family members can come to visit. Often, the family places pictures
of the deceased on the boxes. Religious icons, incense and burning candles
are seen in the right foreground. Photo by the author.
















APPENDIX B
SAMPLE DOCUMENTATION FORMS

Inventory


Site
Feature/Burial Number


Skeleton
Date


1 = 75-100% present (complete)
2 = <75% present (fragmentary)
3 = absent


Left Right


Left Right


Sphenoid
Zygomatic
Zygomatic Arch
Maxilla
Palatine
Mandible

Os Coxae
Ilium
Ischium
Pubis
Acetabulum
Auricular surface


Centrum Arch


Frontal
Orbit
Parietal
Occipital
Temporal
TMJ

Clavicle
Scapula
Body
Glenoid f.
Patella
Sacrum
Sternum










Ribs Left Right
1
2
3
4
5
6


Proximal
Epiphysis


Proximal
1/3


Left Right


Middle
1/3


Distal
1/3


Left humerus
Left radius
Left ulna
Left femur
Left tibia
Left fibula

Right humerus
Right radius
Right ulna
Right femur
Right tibia
Right fibula


Left
Scaphoid
Lunate
Triquetral
Pisiform
Trapezium
Trapezoid
Capitate
Hamate

Carpal Phalanges Left
1st prox


MC1
MC2
MC3
MC4
MC5


Right


prox
medial
1st distal
distal



Calcaneus
Talus
Cuboid
Navicular
Medial cuneif
Interm. cuneif
Lateral cuneif


Carpal
Sesamoids (#)


Left


Right


MT1
MT2
MT3
MT4
MT5


Distal
Epiphysis


Right


Left


Right


Left


Right











Pedal Phalanges
1st prox
prox
medial
1st distal
distal


Left


Right


Pedal
sesamoids (#)


Adult Sex/Age


Site
Feature/Burial


1 female
2 male
3 ambiguous


Left Right
Ventral arc
Subpubic concavity
Ischiopubic ramus ridge
Greater sciatic notch
Preauricular sulcus
Estimated sex, pelvis


Left Mid Right


Nuchal crest
Mastoid process
Supraorbital margin
Glabella
Mandible
Estimated sex, skull


Age


Pubic symphysis
Suchey-Brooks
Phase/Stage:
Age:


Left


Right


Left Right


4th sternal rib
Age:


Estimated age: Very young adult (-18)
Young adult (20-35)
Middle adult (35-50)
Old adult (50+)


Skeleton
Date










Subadult Measurements


Site
Feature/Burial Number


Cranial:
L R
Lesser wing of sphenoid
Length
Width
Greater wing of sphenoid
Length
Width
Body of sphenoid
Length
Width
Petrous
Length
Width
Basilar occipital
Length
Width
Zygomatic
Length
Width
Maxilla
Length
Height
Width
Mandible
Body length
Arc width
Half length


Postcranial:


L R


Clavicle
Length
Width
Scapula
Length
Width
Spine length
Ilium
Length
Width
Ischium
Length
Width
Pubis
Length
Humerus
Length
Width
Diameter
Ulna


Radius


Femur


Tibia


Fibula


Length
Diameter

Length
Diameter

Length
Width
Diameter

Length
Diameter

Length
Diameter


Skeleton
Date










Immature Age Epiphyseal Union


Site
Feature/Burial Number


Blank = unobservable
0 = open
1 = partial union
2 = complete union


Cranial
Spheno-occipital
Synchondrosis
Occipital
Lateral to squama
Basiliar to squama
Vertebrae
Cervical
Thoracic
Lumbar
Scapula
Coracoid
Acromion
Clavicle
Humerus
Head
Distal
Medial epicondyle
Radius
Proximal
Distal
Ulna
Proximal
Distal


Os Coxae
Iliac crest
Ischial tuberosity
Femur
Head
Greater trochanter
Lesser trochanter
Distal
Tibia
Proximal
Distal
Fibula
Proximal
Distal


Age:


Skeleton
Date










Pathology


Site Name/Number
Feature/Burial Number
Burial/Skeleton Number


I. Bone
II. Exact
III. Side
IV. Section
V. Aspect

VI. Pathology


Bone
Exact
Side
Section
Aspect

Pathology


Observer
Date
Age

Bone
Exact
Side
Section
Aspect

Pathology


Photograph_


Photograph


Photograph









Skeletal Pathology Code Sheet


I. Bone: element
II. Exact: region of element
III. Side: R, L, R&L
IV. Section:
Proximal epiphysis, intra-articular Middle 1/3 diaphysis
Proximal epiphysis, extra-articular Distal 1/3 diaphysis
Proximal 1/3 diaphysis Distal 2/3 diaphysis
Proximal 2/3 diaphysis Distal epiphysis, intra-articular
Middle 1/3 diaphysis Midshaft
V. Aspect:
Superior Anterior
Inferior Circumferential
Medial Exocranial
Lateral Endocranial
Posterior
VI. Pathology:
Fracture
Type: Complete Partial (Greenstick)
Bowed (note direction) Impaction (Compression)
Segmental (#) Avulsion
Burst Comminuted (#)
Spiral Oblique
Depressed, outer table only
Depressed, inner and outer tables
Pathological
Shape: Round Ellipsoidal
Edged (sft) Projectile (entry, exit, embedded)
Radiating Amputation
Number of defects
Length, depth of each
Ante/Peri/Postmortem: Clear, Ambiguous
Sequelae:
Woven callus Sclerotic
Healed Nonunion /pseudoarthrosis
Necrosis Infection
Traumatic arthritis Ankylosis
Myositis ossificans
Length (mm): Normal, Shortened
Apposition (%)
Rotation: Internal, External
Angulation (degrees)
Treatment
Mechanism
Dislocation: Traumatic, Congenital, Ambiguous