Adult scurvy in New France: Samuel de Champlain's "Mal de la terre" at Saint Croix Island, 1604-1605

Diagnosing scurvy (vitamin C deficiency) in adult skeletal remains is difficult despite documentary evidence of its past prevalence. Analysis of 20 European colonists buried at Saint Croix Island in New France during the winter of 1604-1605, accompanied by their leader Samuel de Champlain's eyewitness account of their symptoms, provided the opportunity to document lesions of adult scurvy within a tightly dated historical context. Previous diagnoses of adult scurvy have relied predominantly on the presence of periosteal lesions of the lower limbs and excessive antemortem tooth loss. Our analysis suggests that, when observed together, reactive lesions of the oral cavity associated with palatal inflammation and bilateral lesions at the mastication muscle attachment sites support the differential diagnosis of adult scurvy. Antemortem loss of the anterior teeth, however, is not a reliable diagnostic indicator. Employing a biocultural interpretive approach, analysis of these early colonists' skeletal remains enhances current understanding of the methods that medical practitioners used to treat the disorder during the Age of Discovery, performing rudimentary oral surgery and autopsies. Although limited by a small sample and taphonomic effects, this analysis strongly supports the use of weighted paleopathological criteria to diagnose adult scurvy based on the co-occurrence of specific porotic lesions.


Introduction
Scurvy, long the scourge of sailors, results from a prolonged deficiency of dietary ascorbic acid (the reduced forrn of vitamin C) or the inability to metabolize adequate amounts of the vitamin. The clinical manifestations of severe vitamin C deficiency (avitaminosis) arise because unlike n-rost other mammals, humans are unable to synthesize ascorbic acid and must maintain its regular intake, mainly from fruits and vegetables. Consequently, the disorder reflects a complex con-rbination of human physiology' socioeconomic factors, and environmental conditions (Sl'r':-: ",:'.}'i.ri: a":.:.' ,'.j:::','.t':'. . illiji;: l-:':r.:;;"r*. ---1., :"l,liir: :laii'r.:::-.:l:l{: :. .1'1L111'.,l.il;:li), SUCh that anthropologists l-rave interpreted its prevalence as an indicator of social or environmental stress (e.g., Because of the difficulties in accurately identifying nutritional deficiencies among human remains from populations where significant malnutrition was known to have existed, numerous authors have noted that scurvy is particularly underreported (,'r'r:ii:'r'l  much to subadult ontogeny being more sensitive than adult biol-46 ogy to environmental and socioecononic stressors (:.'.,;.''::lli.;:l 'rrr.l a1 ) and the hemorrhagic effecrs of scurvy are more pronounced on developing bones. In adults, clini-4s cal symptoms take months to appear and gross skeletal lesions are 50 Oftennotvisible(i::lll.:i'.r-r,.'lil'-: ,:i':'r ::i;r';':l : ''.:;:.:'::':.',)'."::.';'). 5r a;:;i I :ara' i Il::.i,:., i ::r;i:'l conducted the firstin-depth studyof 52 adult scurvy using an archeological skeletal sample of 50 men found 5l in a late seventeenth-century Dutch whalers' cemetery at  bergen, an archipelago located about 600 miles north of Norway. s5 He concluded that scurvy was the most likely cause for the high io prevalence of black maculae (stains)that were present on the artic-57 ular surfaces of the lower limb joints (hemarthrosis) in virtually 58 all of the individuals available for study. Based  Samuel de Champlain to colonize New France and died at Saint Croix Island, Maine, during the winter of [1604][1605]. Their graves were excavated in 1969 and again in 2003 on this six-acre island located in the middle of the Saint Croix River, which serves as the border between the U.S. and Canada. Champlain's documentation of the symptoms of the afflicted, which he called "mal de la terre (land sickness), otherwise scurbut" (fir.::l'::',:i::. ili.,l ' i I ti l:ll::ll: i i'epresents the only known case in the historical literature in which an eyewitness account of the suspected disorder is available to accompany the paleopathological analysis of recovered bones. The purpose of this analysis is to test whether skeletal lesions potentially consistent with scurvy indeed existed among the remains of these men. The results also address the questions: (1) did Champlain correctly recognize the disorder:rr 12) how did these Renaissance-period colonists attempt to treat scurvy at their early settlements in New France?

Clinical symptoms and paleopatholory of adult scurvy
In both adults and children, the clinical symptoms and skeletal lesions associated with scurvy result from defective collagen formation in normal connective tissue and small hemorrhages or "leaking" of blood through the voids in the walls of arteries and veinS (l-,.i,:i,; .:i:',j ::l'.lill li','.:"'. "lr.lrl:ll L,:ri:i;::: ,1i....:ii1:). ASCOTbiC acid is a critical component in biosynthesis of collagen, serving as the "cement" that binds together the connective tissues. Prolonged deficiency of dietary ascorbic acid, genetic anomalies, and other disease processes also depress the normal osteogenic activity of osteoblasts in otherwise normal bone tissue, reducing and finally halting the formation of new bone.
Scurvy is clinically recognized in adults through its hemorrhagic manifestations, especially bleeding gingiva, ecchymoses due to bleeding into the subcutaneous tissues, hernarthrosis, and perifollicular petechiae (i-,:r,: ,:.1 ..i,. .:l:::r.': 1rl.':::,';'r'::.:i lil:-ll:l:, )i) r.:). In many victims, the gums become so swollen and blackened that teeth are obscured. Secondary infections arise from inadequate dental hygiene as inflammation spreads across the mucosal tissues that cover the hard and soft palates and the gums. Teeth become loosened as inflammation drives resorption of alveolar sockets, allowing especially the anterior single-rooted teeth to exfoliate. Wound healing ceases, and anemia may result from bleeding and inrpaired iron absorption.
Over the winter the men subsisted on Spar-rish wine, frozen cider, melted snow, and "salt meat ar-rd vegetables" ('i.lr'i::rl:1,.::'-. :ii:-l I 1 * I i l: :.1i.-ii*lf) I t. i.,hamplain reported that 35 men died during that winter and were buried on the island. Ascribing all of their deaths to scurvy, he detailed the affected men's symptoms (l i'l:::rl:1.::::' : ll::,' i I S'i i j: .lti-l**i" e:-i:i:i'llogical excavations for the U.S. National Park Service in the 1950s revealed tl-re location of the cemetery (i!;:r,:;r"' ,i;.::;. ) More extensive excavations in lg6g identified 23 individuals in the cemetery (:-,',.rr1':!r ll:; : -). Cruber's team removed the best-preserved bones ar-rd teeth to Temple University in Philadelphia where tl-rey were later studied in greater detail ( --:':::',,,, r., i:,:,:t). Excavations in 2003 to rebury the remains revealed two more graves and provided an opportunity to systematically examine each individual's skeleton j:r sitrl (f l" :: ': i ;.;.. 'lll L 1: :,r: ;r:,-l 1il 3.2. Scurvy in fhe rqi" iJ:.scovery Afflicting human societies for millennia, vitamir-r C deficiency was well known br-rt little understood during the Renaissance. Outbreaks of scurvy became more regular on European ships as their ranges were extended, especially on voyages to the New World and into the Pacific Ocean (:,.:ir:',':;i:,'l'. 'l ir.:.i:i). Accounts of the disorder begin to appear in French naval reports and sailors'journals in the middle of the sixteenth century; among the best known is tl-re description byJacques Cartier i.1491-1557) as scurvy ravaged his crew in 1536 while he explored the St. Lawrence River (l-i;ri1::' 1 r,': ,. | 1 5:i 5 1 ) By the time that Champlain had landed at Saint Croix Island in 1604, he and many of his fellow sailors had themselves witnessed the devastating effects of scurvy on board ship as well as among communities on land. Incorrectly considered two different types of the disorder, various dietary and sometimes dangerous non-nutritional remedies were attempted to treat "land" and "sea" Absent an understanding of the roles that vitamins play in human physiology, the settlers at Saint Croix lsland were limited to treating only the scorbutic symptoms that they observed. Champlain and other writers of the period focused on the most grossly obvious symptoms of the mouth and skin. Medical practitioners of the time were virtually powerless to effectively treat the effects of scurvy. As such, autopsies to determine the disorder's cause were reported by several French explorers, including Cartier and Champlain. Autopsies were generally uncommon during this period and performed when all other treatments had proven ineffective.

Skeletal sample
The remains in 20 ofthe 25 graves excavated at Saint Croix Island were sufficiently preserved to determine their demographic profiles, but infracranial preservation was poor. The skeletal remains that had been brought in 1969 to Temple University included the mandibles and associated teeth from 19 individuals and the incomplete dentition with mandibular fragments from four others ( ). Four ct'ania also comprised part of this original sample, as did the complete palate from one individual and the long bones from five others. Of the five individuals whose long bones were recovered, two also included their crania.

Analytical methods
Skeletal and dental inventories, demographic assessments, osteometric data, and descriptions of lesions among the skeletal Table 1 Summary inventory of skeletal femains excavated at Saint Croix Island.

I. Demograplfic profles
Of the 25 individuals excavated at Saint Croix Island, analysis indicated that 20 were men of European or indeterminate ancestry (...,t:,]:: .,'). The sex and ancestry of the otl-rer five were indeterminate. Fifteen of the 25 individuals (60%) were 'i0-30 years old at death; three other individuals (12%) were at least 30 years old.
Burials 10 and 21 were the youngest individuats (each i 8-22 years old) and Buriat 3 at i5-40 years old was the oldest individual of the group. The five individuals represented only by teeth or tooth crowns (Burials 13-16 and 24)were all at least 20 years old based on the desree of occlusal attrition.

Patterns and prevalence of pathological lesions
None of the remains exhibited evidence of antemortem trauma.
Evidence of pathology related to infection or inflammation, however, was observed on almost every set of available skeletal fenlalns.  included individuals with l-rard palates sufficiently preserved for visual examination. Of these 16 individuals, 15 (94%) exhibited abnormal porosity of the palatal surfaces, primarily extending from the incisive foramen posteriorly to the first molars and, in some cases, to the transverse palatine suture (': ,,:i':,1 :i). The porosity was bilateral, mildly to moderately dense, and active. The individual pores measured between 0.5 and 1.0mm and were more prominent on slightly raised areas (irrl., i). In addition to the abnormal palatal porosity, mild to moderate palatine tori were present in eight of the 16 observable palates ('.';:.::: :i; rr';1. l). Also, fragmentation of the maxillae from nine of the men allowed obsefvation of the internal surfaces of their maxillary sinuses. In eight of the nine individuals (89%), the floor of at least one sinus exhibited fine to dense porosity bone that was active at the time of death ('r ,r:r ; :"). ln three ofthese cases (Burials 2, 10, and 18), the roots ofat least one maxillary molar had perforated the sinus floor prior to death.  ' Presents reactive bone bilaterally on the posterior maxillae at the proximal attachments for the superficial heads ofthe medial pterygoid muscles.
Apart from the maxillary lesions, porosity also was present along the lingual surfaces of the mandibular horizontal ramus in 15 of the 18 n-ren (83%) with at least one observable side ('i;:rir"':). Both horizontal rami were observable and the porosity was expressed bilaterally in eight of these 15 individuals (53%).ln all of the cases, the porosity was most prominent surrounding alveolar the sockets of molars.
Although the majority of the men excavated at Saint Croix Island had retained their teeth, excessive porosity and exposed coarse trabeculae reflecting inflammation and resorption of alveolar bone was observed in all their observable tooth sockets. These degenerative changes were particularly prominent in the molar sockets where most of the biomechanical forces of chewing are exerted and the lamellar bone is thin.

Lesions associated with the muscles of mastication
Among the 19 men from Saint Croix Island with at least one observable ascending ramus, five (26%) exhibited porosity located on the medial surface near the mandibular foramen ("i :l:;,: '1 ). In two of these individuals (Burials 1 0 and 19) the porosity was dense and active. The porosity was bilateral on Burial 10's mandible, but the left ramus from Burial 1 9 was not observable. Burial 10 was the or-rly individual among the four with porosity whose ascending rami were both observable; his remains demonstrated bilateral lesiot-l formation.
Four of the men exhibited porous lesions on the pterygoid plates and associated fossae of their sphenoid bones. These parts of the spl-renoid bone were observable in seven of the 25 men excavated at the island. The four with sphenoid bone porosity represent 57% of these seven individuals ( i .: l:l:: .:l ). Two of the four individuals (Buri- and only mild to moderate occlusal attrition. Of the 14 n-ren with rso both their maxillae and mandibles available for examination, nine r8r of them (64%) retained all of the teeth in their sockets at death. In rsl three more (21%),the teeth were all present in one arcade. Conserrl quently, 1 2 of the 14 individuals (86%) died with virtually all of the 3s1 anterior teeth present in their sockets ( i';l",l..' -:). Of the 1 5 individuals with at least one femur or tibia sufficiently r8l preserved for examination, eight (53%)exhibited porotic periosteal r88 reactive bone on diaphyseal surfaces. Six ofthese cases manifested r8e bilateral lesions ('i'':ilr:, r:i). The porosity was generally coarse and 3e0 diffuse with indistinct margins. It was most prominent at the musrer cle attachment sites on the posterior surfaces of the femora and rel tibiae but also observed on the anterior aspects of these bones. The 3el periosteal lesions were scored as active in all eight of these individ-re4 uals; one of them (Burial 5) also exhibited moderate osteomyelitis re5 of both tibiae and the right fibula with both active and healed rre6 periosteal lesions. The left and right femora were observable in rel 13 individuals, and porous lesions were manifested bilateral on ret seven of them. Of the 11 n-ren with both tibiae observable, four ie!) exhibited bilateral porous lesions. Four men exhibited these lesions 400 bilaterally on their femora and tibiae. 40r Four men exhibited reactive lesions most likely resulting from 401 inter-articular hemorrhages, or hemarthrosis. In Burial I, areas of 401 porous bone with macroporosity were present within discolored 404 areas of the articular surfaces of the femora, tibiae, and tali (prn.'l). 405 In Burial 5 numerous small, circular areas of cortical porous bone 4rn were present across the posterior halves of both femur heads. Addi-4rl tional areas ofporous bone were recorded on the inferior surfaces of 40i his femoral condyles and within the intercondylar notches. Burial 40e 10's right tibia exhibited mild reactive bone with porosity on its 4r0 proximal articular surfaces and eminences. The coarse porosity was 4n I' r'r's,'r't l.',1t i )1 9 !r i

Evidence of medical treatment and autopsy
There is evidence suggesting at least three men had been subjected to medical treatment involving removal of swollen maxillary gingival tissue by the settlement's surgeons and at least one autopsy. The right sides of the palates fror-r-r Burials 9 and .l 0 were both absent, yet the left sides lacked any indication of postmortem erosion and appeared healed, with no observable cut marks (; :-r:r ;,r r.,:l :r ). None of the n-raxillary right anterior teeth from these men were present. The maxillary left teeth and most of their Table 5 Status ofanterior tooth ioss amons the individuals buried at Saint Cfoix Island.  mandibular teeth, however, were present and intact in both of these 416 individuals. The maxillary arcade of Burial 22 was completely edenzl tulous with only a thinned and resorbed margin remaining where cr the sockets for the anterior teeth had been (:::, ''r); there were no 4:e observable cut marks. The appearance of this man's palate was r30 inconsistent with postrr-rortem erosion and none of his maxillary 4l teeth were for-rnd loose in his grave, altl-tough all of his mandibu-4rl lar teeth were present in their sockets. Further, Burial 22's right 4r.l mandibular teeth displayed occlusal attrition and dentin exposure, 4r4 indicating that the maxillary teeth had been in occlusion for some r.r5 time. Burial 10 exhibited clear evidence of a symmetrical, trans-116 verse cranial autopsy cut through the cranial vault, allowing the 431 calvarium to be removed for examination of the brain and then 4rr replaced prior to burial. riq

Obsented signs of illness
Chan-rplain's thorough account of the colonists' symptoms and complaints 1 tr.r,r. i !r-: i .l l: lf)l*ll}*i i: very similar to those itemized in l.,,',: :'r .:i ".r: :.j :. Champlain paid particular attention to changes in the mouth and dentition, commenting on the swelling of gum tissue ("in the mouths. . .large pieces of superfluous fungus flesh"), periodontal disease ("which caused a great pLrtrefaction"), limiting their ability to eat solid food ("they could scarcely take anything except in liquid form"), and looseness and loss of teeth ("their teeth barely held in their places, and could be drawn out with the fingers without causing pain"). He discussed the progression of the disease, reporting that the dental changes occurred first and later the men experienced problems with their arms and legs wl-tich became swollen, covered with "spots like fleabites" including "intolerable" pain and difficulty walking. These signs were accompanied with pain "in the loins, stomach and bowels," bad cough, and shortness of breath. He commented on the resulting fatigue ("consequently they had almost no strength"); limited mobility ("the majority of the sick could neither get up nor move"); and syncope ("nor could they even be held upright without fainting away"). In describing their surgeons' autopsy findings, E zzz E z z zz E -zz zzzz z z z z zz =======c====c=7 6YYo oooiiof iioc) g!,:YyLZygtg---<z-< < La -zZzz < < z / < <zz r= 7 '-â q^9^^9;na^n-^-Yĝ K q r I I r : I { I Q q q F g q s s e I 3 g z < z <z z < -z < z z z z < z z z z L z z z Y I Y :YY X :Y : YYYY 9Y<<:i<i\ z -z4 z z << z< z zz zz z z z < z z z v tu u tu tu tu u u y a gV,^yy 6 9 9,V g_r1 K K RP K K F r P x-3 e9-3-3 E_3ts g:!1!-: = a A.a " < <L < < E 2 << E<.< -<z z  have been hematomas ("purple spots") on the thighs, which they incised with a razor revealins clotted blood.

Mortality and mass fatality event
ili:.rr':ti,t,i.::r't ,'i:r':r I 1i: i:i it l*l-iii.i 'prOvided an aCCOUnt Of the prevalence of the illness and deatl-t rate among the colonists during the winter months of ,l604-1605: "of seventy-nine of us, thirtyfive died, and more than twenty were very near it." This number is cor-rsistent with the archeological discovery of 25 graves, along with evidence of erosion of the remainder of tl-re cemetery located near Saint Croix Island's shorelir-re. The high n-rortality in-rpact of the illness that Champlain had identified as scurvy is also consistent with the documented limitations in food availability, which potentially affected the whole colony and put atl of the colonists at risk.

Dffirential diagnosis
Acute adult scurvy is a potentially fatal disease. If vitamin C is entirely absent, the only acute skeletal evidence would be residual effects of hemorrhage, some generalized osteoporosis, and possibly death, which are all difficult to positively diagnose in the skeleton. With chronic deficiency, there is likely to be a more obvious skeletal response in the form of diffuse inflammation due to hemorrhage, especially witl-rin the joints and under the periosteum. The resulting effects include periostitis with hematoma organization and periodontitis with potential tooth loss, and systemic osteoporosis. Inflammatory and porotic changes would be more pronounced in areas with persistent muscle stress or syr-rarthrotic mechanical strain such as those associated with n-rastication. Observatior-rs of the Saint Croix Island remains are limited by differential preservation of the crania and mandibles cot-npared to the infracranial bones.
Differentiation of adult scurvy from other pathological conditions is accon-rplished by observing the generalized distribution of the periostitis on all long bones and the generalized osteoporosis rather than increased density. Scorbutic periostitis is diffuse, and the periosteum may appear somewhat separated from the cortex due to the subperiosteal hemorrl-rage. In contrast, periostitis due to local infection or traumatic insults would tend to be more focal, more tightly bound to the cortex, and might include other characteristics such as cloaca or callus lormation which are absent among the Saint Croix remains. In the differential diagnosis of tl-re scurvy, other similar bone-forming disorders that could produce similar must be considered to see if they were instead responsible for lesion formation. In this sample, such diagnostic candidates are treponemal disease, osteomalacia, hypertrophic (puln-ronary) osteoarthropathy, fl uorosis, and mehlori ostosi s.
Tl-re florid, bulbous, and geographic appearance of treponemal disease lesions of the cranium and long bones is easily seen as a mismatch with the lesions among the men of St. Croix lsland, especially since treponemal disease spares areas ofjoint or muscle strain and is not associated with periodontitis. Although osteomalacia may produce porosity of the trunk and limbs, it neither includes generalized periostitis, nor does the porosity tend to be distributed to the cranium. The lumpy density of hypertrophic pulmonary osteoarthropathy in long bones is differentially thick at midshaft, unlike adult scurvy-affected long bones, which have more uniformly formed periostitis and more porous bone. In contrast to the diffuse periostitis of adult scurvy, long bones affected by fluorosis have subperiosteal accretions that tend to be more focal, 5:l especially at tendon insertions. The porous and less organized texiil ture of adult scurvy periostitis affects long bones generally, and ll does so bilaterally, whereas ir-r mehloriostosis (Leri's Disease) one sr4 extremity tends to be affected only, and the texture of new bone 525 formation resembles that of melted wax (i.r;l-r3 ;'l .ri.. l:ili,:!:, l.]r'irl:'i. 516 ji:i:::i). stl Since scurvy often accompanies other nutritional deficiencies srs including vitamin D deficiency (osteon-ralacia) and anemia, idensre tifying the specific disorder in dry bone is especially difficult in s.it adults, even witl-r well-preserved remains. Differential diagno-5rl sis of the oral abnormalities includes periodor-rtal disease from 5r: poor oral hygiene, non-specific infections, and osteopenia result-r1l ing from other metabolic disorders. The porosity observed on the 5r4 hard palates and mandibular horizontal rami could reflect gener-s15 alized gingivitis and periodontitis. These conditions, however, are 516 typically accompanied by tooth loss and destructive remodeling 5j7 of the alveolar processes, neither of which were present. Poros-538 ity located on the ascending rami at the attachment sites for the sre pterygoid muscles has been associated only with scurvy. Cingivi-540 tis and periodontitis do not affect these areas of the mandible. srr Further, porotic lesions of the cranium also may result from ane-541 n-ria but in these cases are typically accompanied by enlarged ll marrow spaces; these lesions have not been documented in the s44 oral cavity. Porous cranial lesions also may develop as a result s45 of osteomalacia, but without infracranial indicators, it cannot be 546 distinguished from those of scurvy. The presence of a palatine 547 torus is generally considered an epigenetic trait but may be asso-s48 ciated with scurvy, the possible result of biomechanical chewing 54e stress. Likewise, diffuse porous lesions of the lower extremi-550 ties may represent systemic or localized infections of various 55r origins (Ai;;iirr lr:i;.: .:;';,:l !r,rrli"ifr:.ra;: I*Jr-ti:r, l$3i: l.::':r-:::':-'li.fr..r.'. 551 li:; t'l.:t,r. ii. l:i..i:). 551 Based on the association of traits in the weighted criteria 55,1 listed by i::l:-..i.,'rr :t-,i. :r,rr'::: ,.il:i;r:" and the three-level classifica-s55 tion described by i,,.:l;i-, .:::l ir::.. ::.:-! ,.":', ,'i.:, tl-re skeletal data were 5s6 re-analyzed ( l;,':l;,r.r 5 r:::r ,i). Of the 15 individuals with observable s57 skeletal elements, eight (53%) were diagnosed with probable scurvy 5i8 and six (40%) with possible scurvy. Burial 10 probably suffered from 55e scurvy based on the presence of the autopsy cut, evidence of oral s60 surgery together with a maxillary torus, reactive bone across his 56r hard palate, along the lingual surfaces of his mandible, and on the 561 medial surfaces of his ascending rami. There also were active porous )61 lesions on both of his femora. Diagnoses of probable scurvy were 564 made for seven other individuals ('i ;,:.rit '' ). Two men (Burials 9 and s6-s 22) exhibited reactive bone across their palates, the lingual sut'-5hn faces of their mandibles, pterygoid plates, n-redial surfaces of their s6i ascending rami, or a combination of these locations along with 56r evidence of oral surgery. Diagnoses were made for the other six 56e ir-rdividuals based on combinations of these lesions. Possible scurvy 570 was identified among six other men whose remains were less com-571 plete or exhibited fewer lesions. Ten other individuals were not s72 sufficiently preserved to apply the diagnostic criteria.
irl There is presently no single pathognomic indicator of adult s74 scurvy in the skeleton. Diagnosis of the disorder depends on the 575 coincident presence of porotic lesions reflecting its l-remorrhagic s76 effects in the mouth and lower lirnbs, evidence of hemarthrosis, 5ij and generalized osteoporosis. Hard palate porosity is too colrllron 57t among archeological remains to be diagnostic alone, and requires s-q the presence of lesions associated with other areas of oral inflan-r-5r0 mation and at the attachment sites for the muscles of r-r-rastication -iirl to indicate scurvy. Because of the incomplete nature of the remains 5sl from Saint Croix lsland, other nutritior.ral disorders and infections 5sl cannot be entirely excluded as possible causes for their porotic 5s1 lesions. Chan-rplain's historical documentation and context, how-585 ever, makes it likely that scurvy was a factor in their deaths.  affected at least several of them. As early seventeenth-century 60e trans-Atlantic sailofs, they were at high risk for nutritional defi-610 ciencies, especially scurvy. Faunal remains recovered from one of 6rr tl-reir trash pits and cooking vessels from other features at Saint 6rl Croix Island, as well as documentary data regarding the culinary 613 trends of the period (:::,'i:ai::!, li:il; |tlrr.i:rl':'fi 'i1.. ll:i)), reflect 614 restricted diets that would not have provided adequate vitamin C or: to the men, particularly dr-rring tl-re severe winter when they were 61.6 trapped on the island. The archeological data indicate that they nr? subsisted largely on salted meat and grain frorn France, local wild-.rhi fowl, fish and shellfish, seal meat, and possibly native fruits and 6re berries, but the latter was restricted to the noblen-ren among the 6:0 group. Spanish wine and cider also were available, although the 6ri cider froze during tl-re winter as did their fresh water supplies. 611 llr.i;r:t.'l.tir: ' 1:: ).i l,,::: :: i: ?7?-2.1:.., wrote that they had planted 6rr wheat on the mainland and built an oven for baking, but that noth-614 ing grew well on the island itself. Except for the berries, clams, and 6:j mussels, these foods contain little vitamin C and even less if cooked. 6:6 Finally, Samuel de Champlain's own journal provides a first-person 617 account of the symptoms of the disease that he identified as the 6:8 cause of death for 35 of his comrades. Ulceration of the gums follows, accompanied by the formation of 65i pyogenic fistulae along the alveolar processes. Scorbutic adults also 654 present proliferation of the interdental papillae that leads to forma-65s tion of pea-sized nodules between the teeth ( :;;,:l: i., ; 1.. -,:r.-:.::rr). 656 These nodules often form between the anterior teeth and are par-6s7 ticularly noticeable; Champlain's reference to "fungus flesh" may .,5s refer to these lesions. Lescarbot included a similar account of the 65e gum lesions based on his conversations with the Saint Croix Island 660 survivors: "Meanwhile the poor patients lay suffering. . .hindered 661 by a foul flesh which grew very abundantly in their mouths, and .,61 which, when they thought to root it out, renewed itself daily more 661 abundantlythanbefore" (';.:.:,tt..rt:::t:':. :,:: r illl;Si:?i?*.,1!!). ,,64 Some researchers have identified inflammation from local-665 ized hemorrhages at muscle attachment sites as pathognomonic 666 of scurvy, especially the muscles of mastication (the temporals, ocr mediat pterygoids, and lateral pterygoids). These three paired mus-668 cles extend from the sides of the cranium to different locations 6.rl on the medial surfaces of the ascending ramus of the mandible. 6tt) Porosity at their insertion sites in dry bone has been interpreted as 67r reactions to leaking ofblood from branches ofthe internal maxillary cr: artery, which lie deep to and supply these muscles when they are 671 abraded when they contract during chewing ( Differential diagnoses oladult scurvy at Saint Croix lsland utilize a critical evaluation of the appearance and distribution of lesions observed throughout the entire skeleton in combinatiot-t with historical data. Incornplete or fragmentary remains limit assessment, potentially contributing to the condition known as the "osteological paradox" whereby the absence of skeletal lesions is too simply accepted as an indication of good health (i';,.:r:i ::l ',i., :'::'l::'-). In fact, skeletal lesions may reflect an individual's survival despite the presence a disease or disorder, actually a sign of health. However, in this case, it appears clear that the lesions observed here likely owed to deeply dysfunctional physiology and biological stress in the months leading up to their deaths. Bioarchaeology promotes a biocultural approach incorporating multiple sources of evidence, including documentary, ethnographic, and archeological data, into descriptions ofhealth and disease among past populations to overcome, or at least reduce, the effects of the paradox (.rt:;;'::'1;'L::r,. Although swollen and bleeding gums are clinically documented scorbutic symptoms, the traditional sign of the disorder in adulthood is the loss of teeth. Numerous anecdotal accounts written over the centuries include this clairn (ii.:.,'.:::r.'.:i-it::r . i.'r1 r::lliL'r. .: :,1:li:') and paleopathologists have interpreted the absence of anterior teeth as indicative of scurvy, especially if porotic lesions or ossified subperiosteal hematomas are present elsewhere in the skeleton (e.9.' ) In his joulnal, Champlain specifically linked the loss of teeth among the settlers at Saint Croix Island to scurvy: "Their teeth barely held in their places, and could be drawn out with the fingerswithoutcausingpain"(i:::t.;:,:),:rii, ii:-r.:ltir'l3l:301)"h,lodern clinical data from experimental scurvy in adults, however, indicate that tooth loss is more likely the result of poor dental hygiene than a direct effect of the disorder (i.: -;.::::: :l .::.. l::i11.r,. l:]:! i; j'r'-r:,:. ;:::ll). Assuming that some of the individuals recovered from Saint Croix lsland were scorbutic when they died, the dental evidence from this group is more consistent with tl-re experimental clinical data indicating that tooth loss is an unreliable indicator ofscurvy. Despite its depiction in popular culture and Champlain's own journal description, more than 85% of the observable individuals had died with atl of their anterior teeth intact except for the three men whose swollen maxillary gums appear to have had been cut away by the settlement's surgeons. Lescarbot provides a vivid description of the excessive swelling of the gums and associated oral tissues in the cases of scurvy that he observed at Port-Royal, Nova Scotia in 1606 and 1607, which was the settlement that the survivors from Saint Croix Island built in 1605. In his discussion of scurvy (1911 i 1$lilll: 157), he noted that, "And our patients, even though their mouths were sore, and they could not eat, never lost their taste for wine, but took it through a spout, which saved several from death." Postmortem erosion could account for the loss of the palatal bone and lack of loose teeth. However, the straight margins and remodeled (healed) appearance of the remaining maxillae are more consistent with Champlain's description of surgery than an alternative taphonomic explanation.
The excavation of Burial 10 in 2003 confirmed Champlain's description of the autopsies that were performed in an attempt to combat the disease that stalked their settlement. Burial 10 was also one of the three men who exhibited evidence of oral surgery, and his remains exhibited porous lesions of the hard palate, the horizontal and ascending rami, and right tibia. The remains of his cranium currently represent the earliest evidence of a European autopsy conducted in the NewWorld (l-il::i;,.r-i:.: ;l'ril..'li.;:l.'). In their journals, both Chan-rplain and Cartier described numerous autopsies that their surgeons performed in New France specifically to investigate scurvy.

Conclusion
Documentary, archeological, and skeletal data support Samuel de Champlain's account of scurvy at Saint Croix Island during the winter of i604-1605. While lin-rited by tl-re small sample and taphonomic deterioration, the skeletal evidence suggests that at least 14 of 25 settlers probably or possibly had adult scurvy when they died. The skeletal data also confirm Cl-ramplain's descriptions of their rudimentary attempts to treat it and diagnose it via autopsy.
Far from eradicated, scurvy continues to afflict modern people in all societies who have limited access to fresh foods, whose communities are under siege, or who may have a heightened genetic predisposition for the disorder. Beyond being the scourge ofsailors, scurvy truly is the mal de laterre as Champlain called it four hundred years ago, a truly ancient disease that is now better understood but remains unconquered.
.\eknowledgments This paper greatly benefitted from the thoughtful comments provided by the two guest editors of this volurne,Jane Buikstra, and the two anonymous reviewers. ln addition, Haagen I(laus provided assistance with preparation of the images. We especially thank Steven Pendery and Lee Terzis, both formerly of the U.S. National Park Service, who together successfully directed the excavations of the graves at Saint Croix lsland in 2003. We greatly appreciate their assistance and that provided by their colleagues at Arcadia National