Care for the Infirmed: Severe Cases of Pathology from

the Bronze Age (c. 2200 B.C.)

JAMIE D. VILOS AND DEBRA L. MARTIN
University of Nevada, Las Vegas
ABSTRACT Tell Abraq is a Bronze Age archaeological site on the Persian Gulf coast in modern day United Arab Emirates. At least 286 adults were buried in the tomb over a two hundred year period (2200-2000 BC), their bodies over time
becoming disarticulated and commingled. Several severe cases of pathologies among the remains highlight extreme instances where individuals were in need of support and help from kin or other community members in order to survive and
live with their injury or illness. From these examples, two case studies are presented: one individual with a healed malunion fracture in the radius and another individual with a femur evidencing a dislocated knee. Degrees of pain and disability associated with each malady are assessed by accounts in clinical literature. By integrating ancient ailments with
modern medical knowledge within a biocultural context, ideas about care and empathy within the community are explored. [Keywords: bioarchaeology, paleopathology, Bronze Age, Tell Abraq ]
Although studies in paleopathological literature have
documented severe cases of disease and trauma that imply complications resulting in disability, few have explored the survivability and required caretaking of physically impaired individuals in prehistory (Dettwyler 1991,
Gracia et al. 2009, Hawkey 1998, Keenleyside 2003, Oxenham et al. 2009, Tilley and Oxenham n.d., Trinkaus
1983). In this paper, we utilize the bioarchaeology of
care approach pioneered by Oxenham and Tilley (2009,
n.d.) to elaborate on the relationship between a traumatic
injury or illness and the survival of the afflicted individual. This approach starts at the case-study level and incorporates archaeological and cultural evidence to reconstruct the physical and social environment of an individual. Modern clinical literature is then employed to assess
physical ability, psychosocial health, and pain associated
with the pathology and to evaluate the individuals need
for care. Care in this sense consists of food and water
provisions, shelter, transportation, dressing, personal hygiene, and nursing, among other forms of assistance.
For this article, two case studies were chosen
from several among those that exhibited severe pathological expression. With reference to prevalent pathological literature, the conditions were determined through
differential diagnosis; that is, the diagnosis was ascertained through a process of elimination after description
of observable evidence such as the modified features of
the bone, the type of bone affected, and the age of the
individual. With this knowledge, we can then consider
the origins of the pathology as well as the implications of
care over the course of the individuals term with this
affliction. This is accomplished through the use of current medical and nursing texts while operating within the
biocultural framework of the Middle Eastern Bronze
Age. Through this analysis, we may gain a better understanding of the life histories and culture of the individuals
who suffered severe pathological cases at Tell Abraq and

elsewhere.
BIOARCHAEOLOGICAL CONTEXT
The site of Tell Abraq is located on the Persian Gulf
coast of the Arabian Peninsula in present-day United
Arab Emirates (UAE). It was excavated between 1989
and 1998 by Drs. Daniel Potts of the University of Sydney and Debra Martin of the University of Nevada, Las
Vegas and their team. The earliest archaeological material from Tell Abraq dates to the Arabian Bronze Age or
Umm an-Nar period from 2600 to 2000 B.C. (Potts
2000b). The people of Tell Abraq enjoyed a rich diet
from marine, agricultural, and terrestrial sources such
fish, shellfish, camel, goat, dates, barley, and wheat
(Gutierrez 1994, Potts 2000a). Exotic artifacts such as
linen, hair combs, and ivory items suggest the site also
played a significant role in a trade network involving
areas such as Dilmun, Harappa, and Mesopotamia (Potts
2000a). The only human remains at the site were excavated from a sealed, circular-styled mudbrick tomb dated
from 2200 to 2000 B.C. (Potts 2000a). The tomb is
unique in that it is the only contemporaneous burial site
that was not looted and was otherwise relatively undisturbed. Over time as the tomb was used, a commingled
burial formed as new individuals were interred atop the
old, creating a bed of bone, soil, and artifacts 1.4 meters
thick (Potts 2000a). The commingled nature of the remains creates a unique challenge for analysis because
matching bones to any one individual to examine a complete skeleton is nearly impossible. Of the 286 adults in
the population, we highlight two case studies of individuals who suffered and survived a severe pathology and
would have required aid from other individuals in the
community.
CASE STUDY #1

Proceedings of the Southwestern Anthropological Association, 2011 Vol. 5, Pp. 9-13

ISSN 1941-7500

Southwestern Anthropological Association

Figure 1. Anterior view of radius, case study #1.

fracture which is what is likely to have happened to this
individual (Ortner 2003).

Fractures are the most common traumatic injury, occurring across time, species, age, sex and activity
(Zimmerman and Kelley 1982). While some fractures
attributed to violent trauma can be lethal, this naturally
depends on the location and severity of the break and the
damage to bone and soft tissues. This case study focuses
on an individual who likely endured the significant pain
of a broken arm and dealt with the resulting complications as it healed out of alignment.

Implications
While the human body is incredibly resilient and
most fracture cases are nonlethal, this does not diminish
the effects of caretaking efforts of those who assisted
trauma patients in ancient times, such as at Tell Abraq.
Waldron writes, What is particularly noticeable about
fractures that are found in skeletal assemblages is that the
majority are well healed and in good alignment and few
are found with signs of infection. This must indicate that
there were in the general community, a number of individuals who had the knowledge and the skill to treat and
set broken bones, and that the community was able to
care for the injured individuals during their period of
recovery and recuperation (2009:143). In this case, the
pain at the time of the bone break would have been excruciating. Bruising, broken blood vessels, and soft tissue
damage are just a few of the immediate consequences
(Waldron 2009, LeMone and Burke 2004). The muscles
surrounding the break can naturally spasm, which may
cause greater displacement of the broken ends of bone.
Treatment for a fracture at Tell Abraq would have been
much like todays practices (Swearingen 2007). The bone
must first be reduced or reset into anatomical position,
which was likely to be very painful without surgery or
analgesics. Then the bone is immobilized or restricted
from movement to allow for healing, such as in a splint
(Waldron 2009). The mal-union is a complication as a
result of three possible scenarios where treatment was
ineffective: First, the bone was broken and was never
reduced; second, the break caused a greater dislodging of
the bone and was improperly reduced; third, it was improperly immobilized, and the ends shifted out of position. Based on the callus size, at least six weeks of heal-

Description and Differential Diagnosis

This case features a left radius comprised of four
pieces fragmented post-mortem. Toward the proximal
end of the bone, the diagnostic callus of a healing fracture can be observed. Not only can one clearly see the
crooked line of the misaligned bone, but also of note is
the slight anterior rotation of the radial tuberosity. Normally, in the anterior view of the radius, the tuberosity
faces anteromedially (White 2000). The overall condition
of bone surface indicates an ongoing periosteal reaction,
evidenced by the thickened, pitted surface, which may
indicate a generalized infection occurring on the bone, or
possibly a developing case of osteomyelitis related to the
fracture. Additionally, both proximal and distal joint surfaces display no signs of osteoarthritis.
The fracture appears to have been complete and
transverse or oblique in type (Galloway 1999, White
2000). Other types of fractures such as compression and
spiral are eliminated from consideration, as these are either extremely statistically unlikely to occur on the radius
or do not present the healing pattern as demonstrated in
this bone. According to Galloway (1999), a radial fracture is more likely due to accidental trauma, such as a
fall, rather than intentional. A fall could produce enough
force on the radius as the dominant bone bracing for the
fall. Accidental fractures typically result in an oblique
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ing had taken place before this person died (Waldron

2009). If this individuals arm had completed healing, it
would have resulted in a shortened, deformed limb. A
difference of as little as two centimeters would be drastic
to soft tissue connections, and this individual would have
to become familiar with new mechanics of the arm and
hand (Aufderheide and Rodriguez-Martin 1998). The
limb would remain functional, but used with difficulty,
meaning any tasks involving the arm were limited until
the bone healed and the individual became accustomed to
the changed limb. Everyday routines from subsistence
practices to food consumption and basic hygiene customs
would have been affected.

CASE STUDY #2
This next case study investigates an individual who suffered a possible knee dislocation. With this type of injury, this adult would have been dependent on other
members of the community, but it is apparent that this
individual continued to work out of necessity despite any
discomfort that may have been experienced. The evidence lies in the extensive shiny and polished area of
bone on the articular surface of a femur. This condition is
called eburnation, and it is a diagnostic sign of advanced
osteoarthritis, which is known to occur as a consequence
of a poorly healed fracture or a dislocation over time
(Aufderheide and Rodriguez-Martin 1998, Ortner 2003,
Waldron 2009). Although dislocation of the knee is rare,
complications from ligament, tendon, or muscle tears can
place this joint at risk. Once a dislocation occurs and is
left untreated, pain from the injured joint often ensues.

Figure 2. Inferior view of femur, case study #2.

may account for the angled grooves (Swearingen 2007).
Ligaments in the knee are prone to tears from a variety of
actions, such as falls, twisting, pivoting and overextending the joint (Ortner 2003, Frontera et al. 2008). The
ACL has also been shown to tear from heavy lifting and
squatting while bearing weight, a practice at Tell Abraq
that may have contributed to the trauma (Escamilla 2001,
Meyer and Haut 2005).

Description and Differential Diagnosis

This case features a left femur, with special attention to the inferior surface. The distinctive eburnation
is observed by the smooth, polished, shiny, and depressedarea on the medial condyle. The extent of the eburnation
of this patch is beyond the normal articular surface with
the tibia and displays a strange groove pattern. These
grooves run anterior-posterior on the posterior portion of
the condyle and then curve posteromedially to anterolaterally (about 45 degrees) along the shape of the anterior edge of the condyle. Osteophytes are also observed
on the marginal edges of the medial aspect as well as the
intercondylar notch.
This groove pattern indicates osteoarthritis related to a traumatic event that altered the mechanics of
the joint (Jurmain 1999, Waldron 2009, Rogers and Waldron 1995). A luxation, or a dislocation caused by ligament damage, is the most likely explanation of these observations (Aufderheide and Rodriguez-Martin 1998,
Ortner 2003). An anterior cruciate ligament (ACL) tear in
particular may have complicated this dislocation. The
ACL restricts rotation and forward motion of tibia, and so

Implications
This individual would have experienced a great
deal of pain at the event of the ligament tear. Symptoms
of tears are much like a broken bone, with swelling,
bruising, and tenderness at the site (Swearingen 2007).
Particularly with the ACL, there is even a reported popping sound at the time of the tear. Modern treatment of a
ligament tear, besides surgery, is the RICE method,
short for rest, ice, compression, and elevation. It is unknown, however, what ancient treatment would have
been employed outside of rest. As the soft tissues healed,
this individual would have been limited in mobility. The
joint would have been affected by limited range of motion and ambulatory difficulty (Swearingen 2007). Certainly, this individual was not completely disabled and
continued to function after the incident, as eburnation
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Care for the Infirmed

only occurs after years of repeated joint stress and bone

on bone grinding after cartilage and other soft tissues
have been destroyed or worn away. Without the support
of ligaments, however, the unstable knee joint would also
have contributed to pain over time. Duration and distance
of travel may have changed on a daily basis and was perhaps aided by a walking stick or cane. Depending on the
level of pain, this individual could have continued the
practice of carrying heavy loads, like water, wood, or
perhaps mud-bricks, or performed tasks while seated like
weaving, cooking, or child care.

Escamilla, Rafael F.
2001
Knee biomechanics of the dynamic squat exercise. Medicine and Science in Sports and Exercise 33(1):127-141.

CONCLUSION
Care of disabled individuals in ancient populations is an
emerging topic that merits a closer look. The fact that
severely infected and healed broken bones at Tell Abraq
exist gives testament to an individuals survival with an
ailment, something that would not have been possible
without outside aid. This aid may have consisted of general support such as provisions of food and shelter as well
as possible specialized nursing care as in treatment of a
broken limb. These case studies reveal the nature of care
and compassion of those who helped their sick and injured. This speaks to the character and culture of the
community at Tell Abraq. They valued members who
were limited in their ability to contribute or were otherwise placing a burden on the groups resources. Although
these individuals were dependent on others for support,
their periods of limited activity should not be thought of
in terms of impairment. Their diminished capacity to
contribute to the community may have been offset by
taking on other tasks or roles that were within their abilities. But in doing so, what is less clear is how their social
status may have been impacted. In addition, the roles of
caretakers may have also been socially defined. These
lines of thought are useful queries to gain a better understanding of care and compassion in the community, but
without artifacts or historical evidence, there is only so
much that can be inferred. This research provides a nuanced view of ancient care through a biocultural lens, and
future applications of the bioarchaeology of care approach would prove valuable.

Galloway, Alison, ed.

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Frontera, Walter R., Julie K. Silver, and Thomas D.

Rizzo
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Gracia, Ana, Juan Luis Arsuaga, Ignacio Martinez,

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