Cultural Practices

Ancient Medical Practices Ancient cultures appear to be fairly sophisticated in their medical practices. In the case of the Inca and other populations as well, trephinations were performed with great skill and with a remarkable success rate. It has been determined that among the Inca, based on new bone growth at the procedure site, trephination survival approached an 80% success rate (Verano 2003). Conventional radiography can be used to demonstrate not only the frequency of the medical practice of trephination but also the degree of success as determined by new bone growth at the site (Figure 2.96).

Figure 2.93 AP radiograph showing coaxial needle in place at target organ.

Cultural Cranial Modification What follows is a description of the practice of cultural cranial modification and the contribution made by conventional radiography not only to the recognition of its presence but also to the recognition of the biological impact of the modification practice.

Background Cultural cranial modification (CCM) can be defined as the intentional manipulation of the developing crania of infants to reshape the skull. CCM is accomplished through various cranial binding methods, which range in duration from weeks to years. The biological change that results from CCM procedures remains fixed over the life course of the individual. CCM has been practiced by many cultures throughout the world.

CCM Variations

Annular reshaping. It is the result of circumferential binding of the crania. This binding creates a decrease in cranial breadth and an increase in cranial length (Figure 2.97). Within this classification are three common variations: conical, tubular, and elongated.

Figure 2.94 Lateral radiograph showing coaxial needle in place at target organ.

Figure 2.95 Triangulation and target location shown in a ct axial plane.

Trephination Bone Recovery
Figure 2.96 Healing trephination clearly seen in the skull on the right.

Tabular reshaping. It is the result of an AP compression of the crania. Tabular reshaping results in an increase in cranial breadth, which is in contrast to the annular variation (Figure 2.98).

The Impact of CCM Biological effects: A wide variety of biological effects of CCM have been reported. There appears to be a relationship between CCM and a change in wormian bone frequency (Koningsberg et al. 1993; O'Laughlin 2004). Variations in suture

Pyloric Stenosis Ray Sign
Figure 2.97 Radiograph of annular cultural cranial modification (ccM).
Mayan Cranial Modification
Figure 2.98 Photograph of tabular cultural cranial modification.

configuration and complexity have also been reported (Gottlieb 1978; Blom 1999). Additionally there appears to be a correlation with the development of porotic hyperostosis (White 1996). Pressure necrosis in the occipital region has also been reported (Dietz and Bergfield 2001). There have been conflicting reports regarding the impact of CCM on vascular changes. One study using virtual endocasts made from CT scans of modified Mayan skulls demonstrated minimal effect on blood vessel foramina (MacLellan 2006). Another study reports a redirection of sinuses and meningeal vessel paths as they adapt to the new cranial vault shape (O'Laughlin 1996).

Pathological effects: CCM has also been associated with craniosynostosis (White 1996). Craniosynostosis is a premature fusion of one or more of the cranial sutures. A single suture fusion is referred to as a simple craniosynostosis. Compound craniosynosto-sis involves two or more sutures.

The cranial bones are well developed by the fifth gestational month in normal fetal development. After birth, the anterior fontanel closes around the age of 20 months. The posterior fontanel normally closes around 3 months. Mature suture closure is seen at about 12 years of age, with complete suture fusion occurring in the third decade and beyond.

Craniosynostosis has many clinical implications for the afflicted individual. If it is simple craniosynostosis, the impact is largely cosmetic in nature. Compound craniosynostosis, on the other hand, presents with more grave clinical implications. Compound cran-iosynostosis carries an increased risk of elevated intracranial pressure when associated with bilateral coronal suture involvement. Further, it may also lead to anomalies of venous drainage. Compound craniosynostosis may also lead to a hypoplastic maxilla, resulting in upper airway problems and shallow orbits resulting in ophthalmologic conditions.

Diagnosis of craniosynostosis includes radiography using AP or PA, a lateral, and, if possible, a Towne's projection. In normal cranial flat bone development, radiographically the sutures appear as serrated, nonlinear lines, while with craniosynostosis suture markings appear as linear or are absent with early fontanel closure. Additionally, a skull radiograph

Figure 2.99 Extensive annular cultural cranial modification in this child mummy in Cuzco, Peru.

showing a beaten copper appearance associated with craniosynostosis indicates an increase in intracranial pressure, which may lead to other issues of vascular status and integrity.

Two Subadult Case Studies of CCM Impact Here are two case studies that demonstrate the utility of conventional field radiography in the detection of the biological impact of cultural practices such as CCM (Guillen et al. 2007).

Case #1. The first case is that of an infant mummy under two years of age, likely Incan in origin, in Cuzco, Peru. The mummy presented with obvious annular CCM, demonstrated by major elongation of the skull (Figure 2.99). Lateral radiograph revealed fused coronal sutures (Figure 2.100). To further document suture fusion patterns, a modified Towne's projection was obtained (Figure 2.101). The resulting radiograph demonstrates the

Figure 2.100 Lateral radiograph. Note fused coronal sutures.
Figure 2.101 Direction of x-ray for a modified towne's projection.

fused sagittal suture patterns as well as the completely closed fontanels (Figure 2.102). The fused linear suture patterns and the closed fontanels demonstrate craniosynostosis in this infant mummy exhibiting annular CCM.

There are a variety of clinical disorders associated with premature suture fusion. They include hypothyroidism, hypophosphatemia, hypercalcemia, vitamin D deficiency, severe constriction in utero, and positional molding (a type of cranial modification).

Sutures And Fontanels
Figure 2.102 Radiograph from the modified Towne's projection showing a fused sagittal suture and closed fontanels.
Figure 2.103 Wrapped Chiribaya child mummy bundle.

The fused linear suture patterns and the closed fontanels demonstrate craniosynos-tosis in this less than 2-year-old infant mummy exhibiting annular CCM. It is beyond the scope of the study conducted to rule out the varied differential diagnoses. Although we cannot reliably determine the cause of death, it is reasonable to assume that the CCM, along with the craniosynostosis and its associated clinical disorders, may have contributed to this child's morbidity or mortality.

Case #2. The second case presentation is that of a wrapped infant mummy of the Chiribaya culture at the Centro Mallqui research facility, El Algarrobal, Osmore River Valley, near Ilo, Peru (Figure 2.103). A radiograph taken of the mummy bundle demonstrates an infant with annular CCM (Figure 2.104). An endoscopic route of entry was found on the posterior surface of the mummy bundle near the base of the skull. The endoscope was introduced and manipulated into the cranial vault. The endoscopic image revealed a mottled endocranial surface in the location of the cranial venous sinuses, which was deep reddish brown in color (Figure 2.105). The mottled endocranial surface suggests an increased intracranial pressure may have been present. The presence of residual darkened substance associated with the mottled surface suggests possible clotted, dried blood. This is suggestive of premortem intracranial hematoma.

There are a variety of clinical disorders associated with increased intracranial pressures. They include generalized brain swelling, which in turn may lead to acute hepatic failure, ischemia, pseudotumor development, hypersensitivity encephalopathy, hypercarbia, Reye's hepatocerebral syndrome, and decreased cerebral perfusion pressure. Also associated with increased intracranial pressure is increased venous pressure leading to possible venous thrombosis and obstruction of superior mediastinal or jugular veins. Obstruction to cerebral spinal fluid flow with or without absorption may lead to hydrocephalus, extensive meningeal disease, and obstruction of cerebral complex or superior sagittal sinus flow. Of particular interest is what is called the mass effect associated with increased intracranial pressure. This mass effect may lead to cerebral infarct with edema, subdural or epidural hematoma, and abscess or tumor formation.

Figure 2.104 Radiograph showing extensive annular cranial modification.

The clinical picture of an individual afflicted with increased intracranial pressure includes headache, nausea, vomiting, papillary edema, papillary dilation, and poor senso-rium. Given the radiographic and endoscopic data, this subadult (<6 years) with annular CCM may have been afflicted with increased intracranial pressures associated with a possible intracranial hematoma. Although we cannot reliably determine the cause of death, it is reasonable to assume that the annular CCM and its associated clinical disorders may have contributed to this child's morbidity or mortality.

Conclusions Cultural cranial modification (CCM) may contribute to the increased morbidity and mortality of affected subadult individuals, particularly if CCM is extreme, demonstrated here in terms of craniosynostosis and increased ICP. It could also include other associated biological effects, such as porotic hyperostosis, cranial necrosis, and neurovas-cular changes. Additionally, there is an increased probability of CCM affecting morbidity or mortality if it is associated with preexisting conditions.

Accurate description of form and degree of CCM without needing to unwrap valuable mummy bundles requires nondestructive multimodal paleoimaging techniques. On-site field

Figure 2.105 Endoscopic view of possible dried blood (darken areas), possibly resulting from a premortem intracranial hematoma.

analysis requires the use of mobile imaging instrumentation such as endoscopy and radiography with appropriate positioning to attain desired and diagnostic data. The integration of multiple imaging modalities increases the descriptive/diagnostic potential of collected data.

Future application of spectroscopic reflectance may confirm the presence of dried blood in cases where hematoma is suspected without needing to extract a sample.

Burial Practices: Artifact Analysis Another cultural practice is the manner in which the individual is interred. More specifically, in addition to the burial style, artifacts are often found within a mummy bundle or within the mummy itself. Some examples of these objects include metallic and nonmetallic offerings placed in the oral cavity, ceramics placed with the mummy or within body cavities, headpieces and jewelry fashioned from metal, shells, or textiles, special textiles, pouches, feather or cottonlike padding, medallions, and text written on paper. Conventional radiographs can detect these artifacts and help determine their location. As in all cases of radiographic application, more than one view is required to determine whether or not the object is on the outside or the inside of the mummy. In the case of artifacts with low density, exposure factors, specifically kVp, must be lowered in order to visualize the artifacts; this will be discussed in greater detail in Section III, "Artifact Analysis."

Mummification Method Cultural practices dictate the mummification method used by a particular group or population. These methods may change over time as well. Perhaps one of the most familiar mummification practices is that of brain removal among Egyptian mummies. Conventional radiographs can determine if the cribriform plate of the ethmoid bone has been displaced to remove the brain of Egyptian mummies. Although the most common route for brain removal appears to be through the ethmoid bone, it wasn't the only route. The superior portion of the orbit or eye socket was another route, radiographi-cally documented, for brain removal. A careful radiographic examination of the entire cranial vault is a critical part of a standardized radiographic survey and will be discussed in greater detail in Chapter 5 of this book.

In the case of Egyptian mummies, organ packets were often placed back into the body after they were desiccated outside the corpse. Radiographs, particularly nonscreen images, can often detect the presence of organ packets within body cavities (see Figures 2.4A and 2.4B). In addition, the use of resin throughout the body can readily be demonstrated even with images obtained with intensifying screens.

One method of determining if the mummy was artificially prepared or naturally desiccated is to assess the remains for evidence of organ removal. Recall that the conventional radiograph may not show low-density organ remnants, leading to the assumption that the organs were removed and that artificial preparation was employed. Whenever possible, conventional radiography should be complemented by endoscopy, which may be able to detect organ remnants not seen by radiograph, altering the interpretation of the method of mummification.

In many cases, the mummified body is held within an enclosure, such as a coffin, a bundle, or an urn. Conventional radiographs can determine the body position within the enclosure without having to disrupt the integrity of the container. In this manner, information collected by radiography can help one infer mummification and burial practices of the culture under investigation. The nature of the enclosure also may add to the understanding of how mummification was accomplished, particularly if the enclosure amplified the desiccation process.

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