Procedural standards for Endoscopic Paleoimaging in Anthropological and Archaeological Research

If endoscopy is to reach its full potential as a tool for data collection in anthropological and archaeological research, researchers must continue to explore its application possibilities. If the application of endoscopic methods is limited to the medical approach of target-focused biopsy procedures, the full contribution of endoscopic application will not be realized. With the advancement of the application of this technology as the base construct, we recommend a more global approach. We recommend the following procedural framework as a methodological standard for endoscopy application in anthropological and archaeological research:

1. Visual examination: Starting with a physical and visual exam allows the endoscopist time to become familiar with the challenges associated with the subject—be it human remains or cultural material—under study. The endoscopist should make a cursory assessment of the integrity of the subject to ascertain the feasibility of endoscopic examination. The endoscopist should assess the subject for possible entry routes. It is the opinion of the authors that if no route exists, then no artificial openings should be made. With that said, there are occasions when a radiograph may present the research team with a specific internal target requiring closer scrutiny, such as a pulmonary lesion or internal artifact. In these cases, making an artificial opening must be considered carefully. If the project director believes that the data that could be obtained by using an endoscopic technique are critical to the study at hand, an artificial opening procedure can be conducted. If an artificial opening is to be made, creating a closeable flap is preferred to a punch-hole procedure. Photographic documentation is required. During the initial visual inspection, the endoscopist may establish the instrumentation strategy that will be dictated by the subject and the research objectives.

2. Establish research objectives: Research objectives may be established in a variety of ways. There may be previous work that the current project is building upon, thereby dictating possible specific research objectives. In contrast, the subjects may be newly discovered. In this case, the team would be conducting an initial analysis. In either case, the research objectives should be broad enough so as not to limit the data collection and specific enough not to be vague. For example, an objective stating that an overall survey will be conducted is fine as long as the objectives allow for deeper exploration after the initial survey is complete. Another approach to establishing endoscopic paleoimaging objectives is to state that a general survey will be conducted to collect data related to various anthropological and archaeological constructs, such as age at time of death, presence of paleopatholo-gies, evidence of biomechanical stress, artifact analysis, and so on. In this manner, the research is broad, yet focused on specific data collection goals, while leaving room for discovery of the unconventional or unexpected data the subject may have to offer.

3. Photography:

a. Standard: Standard photography should be used prior to, during, and after the endoscopic procedure. This can be accomplished by the endoscopist or by a trained photographer. We have used both professional photographers and

Figure 6.1 Photograph of linear pressure lines on the backside of this sideshow mummy (circa late 1800s) not seen on initial visual inspection. The lines were likely the result of the supine position of the individual resting on a rack during embalming.

forensic photographers with excellent results. Photography should attempt to document the overall condition of the subject from as many viewpoints as possible. Macrophotography should be conducted when unusual observations are made or when preservation characteristics are unique, such as fingerprints on an ancient subject for example. Review of the photographs is essential prior to proceeding with the imaging project, as often the camera will pick up something that the researchers may have missed during the visual inspection (Figure 6.1). Digital photography, in particular, has made a tremendous contribution to the documentation of procedures in anthropological and archaeological research.

b. Alternate filtering. Alternate filtered photography should be conducted to better differentiate among substances and to "illuminate" cultural structures, such as tattooing.

c. Scientific photography should be included with scale to demonstrate specific or general features relative to size.

4. Radiographic survey: Whenever possible, an initial radiographic survey needs to be conducted. The radiographic survey should provide images of each body cavity using at least two viewing angles. Generally, an anterior-posterior view and a lateral view are the best starting points. Including the extremities in the initial survey ensures that data, such as a healed fracture on a long bone, is not missed. The radiography conducted in this manner will then direct the endoscopic procedures, potentially providing specific targets. If calcified lesions are seen in the pulmonary tissue on the radiographic survey, the endoscopic procedures of inspection and possible biopsy are dictated. If an internal artifact is demonstrated in the radiographic survey, the endoscope can then target that object. It is important to remember that even though the radiograph may not show viscera, the endoscope has the potential to image these low-density structures (Figure 6.2), thus complementing

Figure 6.2 Endoscopic images of low-density internal organic remnants not seen on a radiograph.

the radiograph and adding to the research data. The radiograph also provides data upon which decisions regarding advanced imaging can be based.

5. Reassessment of access points: Artificial openings a. Access points: Once the radiographs are complete, new entry points may become apparent. If a target structure such as an artifact or specific pathology is identified, new efforts can be made to locate access routes that will provide endoscope insertion. Additionally, the radiographs along with the initial visual inspection will help determine if the remains can be safely rotated or moved, exposing surfaces not yet inspected visually for entry points. It is important to consider multiple entry point possibilities for each body cavity. The cranial cavity may be entered, if accessible, from the supraorbital fissure, jugular fora-man, foraman magnum, displaced cribriform plate of the ethmoid bone, other periorbital artificial openings, at the site of cranial trauma, through trephinations, and up through the vertebral canal if there is vertebra disarticulation and little nervous tissue (Figure 6.3). Access to the oral cavity may be made directly through an open mouth, through a decomposed section in the submandibular region, from the nasal cavity, and from the posterior neck region or from the base of the skull (Figure 6.4). The thoracic cavity may be entered through any erosion in the anterior, lateral, or posterior thoracic wall (Figure 6.5). Erosions in the abdominal or pelvic region may also provide thoracic cavity access. It must be noted that an intact diaphragm may block entrance to the thoracic cavity from these lower routes. Using an oral or nasal route, similar to a standard bronchoscopy procedure, can provide access to remnants of the pulmonary airway structures or directly into the thoracic cavity. The abdominal and pelvic cavities may be entered through erosions in the surface of those cavities. A part of the procedure should look for evidence of rodent infestation, which may provide an entry point into the various body cavities (Figure 6.6). Rectal entry route is important for potential coprolite identification and collection. Any bony structures with access to the marrow cavity can be readily accessed. Artifact entry routes will vary and be determined by the location of the artifact within the bundle or remains and its structural characteristics. With any of the access routes, there is a concern of "scope drag" on the edges of that route. Using a small-gauge hollow tube at the entry point and passing the endoscope

Figure 6.3 Various endoscope entry routes into the cranial vault: supraorbital fissure (a), fora-man magnum (B), vascular foramina (c), and through the spinal canal (D).

through this guide can guard against scope drag. We have used modified colorful drinking straws to construct an entry point sheath. A bright color is preferred as it will be easier to retrieve if it inadvertently becomes introduced into the remains. The proximal end of the entry point sheath can be cut and folded back to allow the attachment of standard hemostats, which serves to limit the

Figure 6.4 Endoscopic route of entry into the oral cavity, directly through the mouth. Note that the postmortem dental attrition allows ample space for endoscope introduction.
Figure 6.5 Endoscopic entry route into the thoracic cavity via surface deterioration in the axillary region.
Figure 6.6 This opening on the lateral aspect of the abdominal cavity is the result of rodent activity, providing an endoscopic access route into the abdominal and pelvic body cavities.
Figure 6.7 Endoscope entry point protection sheath secured with standard hemostat.

movement of the sheath and prevent it from being dragged inside the object under study (Figure 6.7). b. Artificial openings: If access to any or all of the cavities is not apparent, artificial openings, in general, should not be made. If the survey radiograph identifies a target of interest such as a specific pathology or artifact that warrants further study, an artificial opening may be considered. If an artificial opening is to be created, researchers must adhere to careful documentation standards. Pre- and postprocedure photographs with scale should be taken. A photograph of the endoscope being introduced through the opening needs to be taken as well. The opening itself should be the smallest possible to allow endoscope introduction. Whenever possible, a triangular flap should be constructed so that the opening can be resealed following the procedure (see Chapter 7, Figure 7.7). The artificial opening can be made through wrappings or through surface integument of the remains. If unwrapping is to be conducted for conservation purposes, endoscopy should be put on hold. Often, new access routes become available following the unwrapping, obviating the need to make an artificial opening.

6. Instrumentation selection: The selection of the endoscopic instrumentation should be determined by the data collection task at hand and the research objectives. Matching the instrument to the task is critical to the success of the procedure. If the subject of study is a set of human remains, a medical or industrial endoscope should be employed. A length of 4 ft (1.22 m) is usually adequate if there is direct access to the body or bundle. If the body is held within a container such as a coffin, a longer scope may be required. The diameter of the scope should be such that entry into the subject is possible and a satisfactory image can be collected. Scope diameters from 4 to 6 mm seem to provide the best images, with the 4 mm scope

right angle near-focus viewing lens.

obviously being able to enter into smaller openings. The smallest-diameter video-scope available is currently 4 mm. Smaller-diameter scopes capture the image differently, and resolution is usually less than when using a videoscope. If the subject has only a small opening, smaller scopes, a scope as small as 1.9 mm in diameter, become necessary, although there may be a sacrifice in resolution. If a room or tomb is to be examined, a longer endoscope, such as a 60 ft (18.29 m) industrial scope or a medical colonoscope, may suffice. Generally, a front view lens is used initially to allow the researcher to maneuver the tip of the endoscope through the internal environment of the subject. If large cavities are devoid of organs or the degree of desiccation or decomposition is such that an image of the entire cavity is desired, a far-focus lens may be employed (see Chapter 4, Figure 4.13). A wide angle far-focus lens works well in such situations as well.

A right angle lens may be used when maneuvering room is limited. A situational example of proper use of the right angle lens is trying to image the sella turcica when the entry point is the supraorbital fissure (Figure 6.8). Illumination strategies should match the task as well. Large vacant cavities or enclosed spaces require the most illumination. In these situations, we suggest augmenting the illumination by using an additional scope or light guide that has large fibers and will therefore increase the illumination potential. If the subject of study is a tomb or room, additional illumination will be required, and this is discussed in Chapter 8.

7. Survey of body cavities: Once an entry route has been established and the instrumentation has been matched to the data collection task, the endoscopist should direct the endoscope with the intention of collecting specific data from each cavity explored. As a guide, we offer the following data collection targets from within the varied body cavities. Please note that data collection via endoscopy is certainly not limited to the lists that follow, and the endoscopist should examine any anomalous image. It is critical that the research team members be present to assist in the interpretation of the images and data collected.

Figure 6.9 Endoscopic view of residual endocranial organic material.

a. Cranial cavity (see Figures 2.105 [Chapter 2], 4.20, 4.21, 4.24, 4.31 [Chapter 4], 6.9, 6.10, 6.11, and 6.12 [this chapter])

i. Presence, location, and characteristics of residual brain tissue ii. Condition of the internal cranial table iii. Condition of the meningeal grooves iv. Configuration and relative depth of the venous sinuses v. Condition of the crista galli and cribriform plate of the ethmoid bone vi. Condition and configuration of the sella turcica vii. Characteristics of suture fusing pattern viii. Presence of organic or inorganic matter

Figure 6.10 Endoscopic evaluation of the venous sinuses in a cranial-modified mummy.

Figure 6.11 Endoscopic view of a unique sella turcica seen endocranially.

ix. Examine inner table for paleopathological data (lesions, porosities)

x. Presence and location of abnormal openings into the cranial vault, such as fractures and trephinations.

xi. Impact of cultural cranial modification b. Oral cavity (see Figures 4.27 [Chapter 4] and 6.13 [this chapter])

i. Presence of oral tissues ii. Evidence of abscesses iii. Determine the degree of dental attrition iv. Determine tooth loss pattern (pre- or perimortem)

v. Presence and extent of caries vi. Evidence of dental modifications vii. Presence of exposed roots viii. Artifacts as offerings ix. Hypoplastic growth arrest lines

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Figure 6.12 Radiograph of endoscope location of a wrapped mummy. endoscopic view of an abnormal opening on the outer table of the cranial vault. The opening seen on the endoscopic image may be the result of a lytic lesion or a projectile exit wound.
Figure 6.13 Endoscopic images showing detail on dental wear and condition. A complete dental inventory may be conducted endoscopically.

x. Dental inventory xi. Assess degree of surface wear xii. Examine for indicators of disease xiii. Examine palatine suture fusing pattern c. Thoracic cavity (see Figures 4.13, 4.28, 4.29, and 4.30 [Chapter 4])

i. Presence of thoracic organs ii. Assess the state of preservation iii. Examine any calcified lesions or target structures iv. Consider a bronchoscopic approach for endobronchial assessment v. Internal thoracic structural status—ribs, vertebrae, etc.

vi. Presence of pulmonary pleural adhesions vii. Presence of cardiac and great vessel material viii. Presence and condition of the diaphragm ix. Presence and characteristics of artifacts d. Abdominal cavity (See Figure 6.14)

i. Presence and condition of abdominal cavity organ remnants ii. Examination and characterization of any artificial packing material iii. Evidence of any coprolite material e. Pelvic cavity (See Figure 6.15)

i. Presence and condition of pelvic organ remnants ii. Examination of bony structures for aging indicators

Figure 6.14 Endoscopic views of abdominal cavity structures demonstrating the level of preservation in this late 19th century arsenic-embalmed sideshow mummy. From left to right: liver, spleen, and diaphragm.

iii. Examination and characterization of any artifacts or packing material iv. Consider rectal entry for coprolite identification and potential sampling f. Bony structures (see Chapter 4, Figures 4.34 and 4.35)

i. Fracture patterns and healing patterns (if any)

ii. Evidence of repetitive biomechanical stress iii. Presence of arthritic changes iv. Presence of indicators of paleopathologies g. Artifacts i. Presence and location of artifacts ii. Characteristics of artifacts iii. Examine for any associations with other artifacts h. Targets identified by radiograph i. Specific calcified lesions ii. Specific arthritic changes

Figure 6.15 Endoscopic evaluation of pelvic region. Shown here is the auricular surface of a Chiribaya mummy used to assist in determining the age at the time of death.

iii. Specific dental features iv. Specific artifacts v. Specific fractures vi Specific cultural modifications i Formulation of biopsy/retrieval plan i Frank discussion of merits or outcome potentials ii. Instrumentation selection

1. Biopsy channel

2. Biopsy tool

3. Biopsy route

4. Modified laparoscopic procedure

5. Collection containers

6. Labeling scheme iii. Preprocedure radiograph iv. Documentation v. Procedural radiograph vi. Postprocedure radiograph

8. Procedural documentation: Procedural documentation and reporting should be conducted in a fashion similar to or as described earlier in this chapter. A postprocedure conference should be conducted with the research team members to relate the endoscopic findings to other data collected and determine additional or future paleoimaging research.

If researchers are able to establish common procedures and a methodological approach for endoscopic applications in anthropological and archaeological research, this powerful paleoimaging tool will continue to expand its contribution in this area of scientific endeavor. By adopting methodological common ground, less of the already precious field study time will be spent reinventing already established endoscopic applications.

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