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Unusual pathological condition in the lower extremities of a skeleton from ancient Israel.

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Notes and Comments
Unusual Pathological Condition in
the Lower Extremities of a
Skeleton From Ancient Israel
Keith Manchester
Calvin Wells Laboratory, Department of
Archaeological Sciences, Uniuersity of
Bradford, Bradford, West Yorkshire, BD7
1DP England
The report by Hershkovitz et al. (1992) is
particularly interesting with regard to the
provenance, burial circumstance, and period
of the specimen. However, this interest lies
not in the diagnosis stated, namely, Madura
foot, but in what I propose is a more likely
diagnosis, that of leprosy.
Madura foot is usually a unilateral phenomenon and the osseous change is characterized by extensive destructive cavitation
with multiple draining sinuses, affecting the
tarsus and metatarsus. In advanced disease
the distal zones of the tibia and fibula may
be similarly affected. Although osseous
ankylosis may occur, possibly associated
with secondary pyogenic sepsis, there is little associated proliferative new bone formation in maduromycosis per se.
In the specimen described the pathological changes are bilateral, affecting the tarsus, metatarsus, and tibiae and fibulae. The
metatarsals described and illustrated in
Figures 5 and 6 exhibit cortical pitting and
irregularity compatible with pyogenic infection secondary to the plantar ulceration
associated with leprous peripheral neuropathy. The metatarsophalangeal and tarsometatarsal joint surface changes may be
associated with septic arthritis. The fourth
metatarsal exhibits shaft thinning compatable with concentric diaphyseal remodelling
(Andersen et al., 1992). The calcanei illustrated in Figures 3 and 4 exhibit gross surface inflammatory change together with the
cavitation and sinus formation of osteomyelitis in the anterior aspect of the right cal0 1993 WILEY-LISS, INC.
caneus. The abnormal talocalcaneal articulation in the left foot is compatible with
talocalcaneal dislocation. This is due to leprous motor and sensory neuropathy creating
a neuropathic (viz. Charcot) joint, and is associated with tarsal disintegration (Kulkarni
and Mehta, 1983; Kulkarni, Mehta, Sane,
and Sharangpani, 1985; Andersen and
Manchester, 1988).The scenario therefore is
of collapsed, anesthetic, and ulcerated feet
with secondary pyogenic infection of deep
and, no doubt, superficial tissues. The sequel of these septic changes is ascending infection in the lower leg producing the bilateral tibiofibular chronic inflammatory
surface change (Moller-Christensen, 1961;
Andersen, 1969).
These pathological changes are almost
pathognomonic of leprosy. The bilateral nature of the lesions indicates that the individual suffered from lepromatous (low resistance) leprosy. The authors comment that
the cranium was fragmentary and it is assumed therefore that the rhinomaxillary
syndrome of lepromatous leprosy (Andersen
and Manchester, 1992)was not observed. No
comment was made about the upper limbs,
but gross osseous normality in the hands
does not negate a diagnosis of leprosy.
This is an important specimen in the history of leprosy. It is one of few from this
early period in Israel and may be contemporaneous with the Judean specimens from
the Monastery of Martillous and the Monastery of St. John the Baptist, described by
Zias (1985). The specimen from Bet Guvrin
is from a family tomb, therefore indicating
that segregation, either ostracism or therapeutic, was not practiced in this case. It is
significant too that this specimen, like all
other early specimens, is of lepromatous leprosy.
Received June 9, 1992; accepted October 2,1992.
Andersen J G (1969)Studies in the Mediaeval Diagnosis
of Leprosy in Denmark. Copenhagen: Costers Bogtrykkeri, pp. 115-116.
Andersen JG and Manchester K (1988) Dorsal tarsal
exostoses in leprosy: A palaeopathological and radiological study. J. Archaeol. Sci. 1 5 5 - 5 6 .
Andersen JG and Manchester K (1992) The rhinomaxillary syndrome in leprosy: A clinical, radiological and
palaeopathological study. Int. J. Osteoarchaeol.
Andersen JG, Manchester K, and Mi RS (1992) Diaphyseal remodelling in leprosy: A radiological and palaeopathological study. Int. J . Osteoarchaeol. 2:211-219.
Hershkovitz I, Spiers M, Katznelson A, and Arensburg
B (1992) Unusual pathological condition in the lower
extremities of a skeleton from ancient Israel. Am. J .
Phys. Anthropol. 88(1);23-26.
Kulkarni VN and Mehta J M (1983) Tarsal disintegration (T.D.)in leprosy. Lepr. in India 55/2):338-370.
Kulkarni VN, Mehta JM, Sane SB, and Sharangpani RC
(1985) Study of tarsal disintegration in leprosy. Proceedings of the International Conference on Biomechanics and Clinical Kinesiology of Hand and Foot.
Madras, India. pp. 121-124.
Moller-Christensen V (1961) Bone Changes in Leprosy.
Copenhagen: Munksgaard, pp. 4 2 4 3 .
Zias J (1985) Leprosy in the Byzantine monasteries of
the Judean Desert. Koroth 9(1-2):242-248.
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pathologic, skeleton, unusual, israel, conditions, lowe, extremities, ancient
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