Serpens Endocrania Symmetrica (SES): A New Term and a Possible Clue for Identifying Intrathoracic Disease in Skeletal Populations Israel Hershkovitz, 1,2 * Charles M. Greenwald, 2 Bruce Latimer, 2 Lyman M. Jellema, 2 Susanne Wish-Baratz, 1 Vered Eshed, 1 Olivier Dutour, 3 and Bruce M. Rothschild 4 1 Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel 2 Cleveland Museum of Natural History, Cleveland, Ohio 44106-1767 3 Department of Anthropology, Universite ´ de la Mediterrane ´e, Marseille, 13385, France 4 Arthritis Center of Northeast Ohio and Northeastern Ohio Universities College of Medicine, Youngstown, Ohio 44512 KEY WORDS endocranial changes; tuberculosis; hypertrophic osteoarthropathy; skeletal population ABSTRACT This paper describes a phenomenon in the endocranial plate, which we have termed “serpens endocrania symmetrica” (SES), and discusses its value as a diagnostic tool. The affected discolored bone area exhib- its disruption of the endocranial surface, lending it a maze-like appearance. Histological sections demonstrate that the process is limited to the most superficial portion of the endocranium, with no diploic and ectocranial in- volvement (sinus areas excepted). Adult skulls (n = 1,884) from the Hamann-Todd collection (HTH), housed at the Cleveland Museum of Natural History, were utilized for the present study. SES was recognized in 32 of the 1,884 skulls studied (1.7%). The frequency of SES among indi- viduals reported to have died from tuberculosis (TB) was 4.4%. The rate of SES in the non-TB sample was only 0.53%. The locations were as follows: limited to sinus area, 28.1%; calvarium (excluding the sinuses), 46.9%; sinus + calvarium, 25.0%. SES was bilateral in 90.9% of cases. Twenty-five of the 32 individuals (78.1%) with SES in the HTH collection had tuberculosis specifically listed as the cause of death. Six of the other 7 individuals had infec- tions other than TB. In 29 of the 32 individuals with SES, infection involved structures within the thorax. As SES was also associated with another osteological phenomenon known to represent pulmonary disease, i.e., hypertrophic osteoarthropathy (HOA; 68.0% of SES individuals also had HOA), SES may be of diagnostic value in paleopathol- ogy for the recognition of intrathoracic disease, and perhaps tuberculosis. Am J Phys Anthropol 118:201–216, 2002. © 2002 Wiley-Liss, Inc. Pathological changes specific to the endocranial table and their correlated diseases have largely es- caped the attention of the anthropological commu- nity (hyperostosis frontalis interna (HFI) excepted). Although not rare in the skeletal record, endocranial pathologies receive only occasional mention in major textbooks on paleopathology (e.g., Steinbock, 1976; Ortner and Putschar, 1981; Zimmerman and Kelley, 1982; Rothschild and Martin, 1993; Aufderheide and Rodriguez-Martin, 1998). Apparently beyond the threshold of X-ray resolution, these phenomena have also eluded medical description (see Resnick and Niwyama, 1988). When studying the human skeletal collection from the Libben site, researchers noticed a high frequency of endocranial lesions among infants and young chil- dren (Lovejoy et al., 1977; Mensforth et al., 1978). These lesions were attributed to a local periosteal re- action following an infectious process in the respira- tory tract. The diverse lesions were regarded as a different manifestation of a single entity. The authors above also noted an association between these en- docranial lesions and periosteal reactions of the long bones. Schultz (1990, 1993, 1997) drew attention to a variety of changes in the endocranium, attributing them to epidural hematomas, meningitis, and anemia. The current study was initiated to characterize one endocranial sign that may have diagnostic po- tential, as others have noted (e.g., Mensforth et al., 1978; Schultz, 1997). We have elected to name the condition “serpens endocrania symmetrica” (SES) (Greenwald et al., 1999). This term describes a phe- Grant sponsor: MAFCAF Foundation; Grant sponsor: Cleveland Museum of Natural History. *Correspondence to: Israel Hershkovitz, Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel. E-mail: anatom2@post.tau.ac.il Received 12 December 2000; accepted 18 December 2001. DOI 10.1002/ajpa.10077 Published online in Wiley InterScience (www.interscience.wiley. com). AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 118:201–216 (2002) © 2002 WILEY-LISS, INC.