My Patients Were Mummies 1536118516, 9781536118513

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FOCUS ON CIVILIZATIONS AND CULTURES

MY PATIENTS WERE MUMMIES

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FOCUS ON CIVILIZATIONS AND CULTURES

MY PATIENTS WERE MUMMIES

MICHAEL R. ZIMMERMAN

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NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book.

Library of Congress Cataloging-in-Publication Data ISBN: H%RRN

Published by Nova Science Publishers, Inc. † New York

CONTENTS Prologue

How to Become a Mummy Doctor

vii

Chapter 1

Why and How We Examine Mummies

1

Chapter 2

The History of Mummy Paleopathology

19

Chapter 3

An Aleut Mummy Comes to Washington

33

Chapter 4

The Doctor Becomes a Graduate Student

43

Chapter 5

Experimental Mummification

57

Chapter 6

Egyptian Mummies in Museums

69

Chapter 7

The Dahkleh Oasis Project

85

Chapter 8

An Egyptian Mummy Is Made in Baltimore

95

Chapter 9

Practicing Medicine in Ancient Egypt

101

Chapter 10

My Oldest Patients

111

Chapter 11

Two Mummies Are Admitted to Harvard

115

Chapter 12

The St. Lawrence Island Iniut Mummy

131

Chapter 13

The Frozen Family of Barrow, Alaska

137

vi Chapter 14

Contents Agniayaaq: A Prehistoric Eskimo Child in Alaska

143

Chapter 15

Paleopathology and Human Evolution

149

Chapter 16

Curios, African Art and Paleopathology

161

Chapter 17

Helmsman’s Elbow: An Occupational Disease of the 17th Century

165

The Salem Witch Trials: Joan of Arc and Ergotism

171

20th Century Paleopathology: A Train Robber and a President

179

Chapter 20

The Manchester Mummy Project

189

Chapter 21

Antarctica’s Frozen Seal Mummies and the Spread of Tuberculosis

195

Acknowledgements

201

Chapter 18 Chapter 19

Epilogue Glossary

203

Bibliography

207

Author's Contact Information

231

Index

233

PROLOGUE: HOW TO BECOME A MUMMY DOCTOR In 1968 I had finally finished my training in pathology at Bellevue Hospital-New York University Medical Center. Five years earlier I had volunteered for military service with the Army Reserve under the Berry Plan, believing that the Vietnam War would be ended by 1968. Dr. Frank Berry, Assistant Secretary of Defense, had developed a plan which allowed physicians to complete their residency training and enter active duty as a fully trained specialist. As the United States Army was heavily involved in Vietnam at that time, it seemed wise to complete my training program. At the tender age of 30, I was then deemed ready by the United States Army to provide my professional services to unsuspecting soldiers, with a rank of Captain (soon to be promoted to Major, as part of the Berry Plan was to credit years of service from the day one signed into the program at the beginning of specialty training). The Vietnam War was still very active in 1968. As a pathologist and fortunately for the fighting men of our armed forces, I had no patient care responsibilities and was assigned to a slot in the Experimental Pathology Department at the Walter Reed Army Institute of Research (WRAIR), which required my active duty to be extended to three years. My assignment was to fulfill a proposal I had developed to make an experimental model of a mostly tropical disorder, the malabsorption

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syndrome, a matter of great interest to the Army in the midst of the Vietnam War. This effort became my first introduction to the governmental approach to matters scientific. My proposal was predicated on performing gall bladder surgery on dogs, but the Colonel in charge of the department informed me that dogs were too expensive and I would have to use rats. A quick glance at a rodent anatomy book revealed that these particular rodents do not have gall bladders! My unfortunate rats rarely survived my fumbling attempts to place a fine tube in their even finer bile ducts and I was left with a failed experiment and nothing much to do other than contemplate a transfer to a hospital in Vietnam. At this point, a mummy, or rather a young student interested in mummies, came to my rescue. Gentry Yeatman, an ROTC medical student at Mississippi State University (MSU), reported to WRAIR for his summer on active duty. Gentry had a long standing interest in mummies and had finally convinced the authorities of the MSU Museum to allow him to perform an autopsy on an Egyptian mummy in their collection. He prudently arranged for an X-ray examination first and it became obvious that this mummy was a fake! Unwrapping revealed it to be constructed of strips of wood and plaster of Paris and neatly tucked inside was an 1898 issue of the Milwaukee Journal. A phrase popular in the 1960s, never trust anyone over 30, was certainly appropriate here. Arriving in Washington, a very frustrated Lieutenant Yeatman approached the Director of Physical Anthropology at the Smithsonian Institution, Dr. T. Dale Stewart, and won permission to examine a mummy from their collection. When a 300 year old mummy from the Aleutian Islands arrived at WRAIR, my Colonel asked (ordered?) me to assist in the examination. Thus in the late summer of 1969 there were three remarkable happenings. Neil Armstrong walked on the moon, the fledgling New York Mets won the World Series, and I did my first mummy. That Aleut mummy became the door through which I entered the fascinating world of paleopathology, the study of ancient disease. I was moved on to another project, an attempt to develop a malaria vaccine (which remains an unsuccessful effort by modern medicine). Aotus monkeys, a nocturnal species known as owl monkeys for their large eyes,

Prologue: How to Become a Mummy Doctor

ix

were the experimental animals of choice but the ability of the malaria parasite to change its antigenic clothing continues to frustrate research efforts. Meanwhile, the examination of the Smithsonian mummy was proceeding, as will be seen in the third chapter. Intrigued by the possibilities of this field, I enrolled in a basic physical anthropology course under the now deceased Dr. Lawrence Angel at George Washington University. Suffering from an excess of hubris, I thought I could get a quick and easy Ph.D. in anthropology (how hard could it be compared to medical school?) and that archeologists and anthropologists would then beat a path to my door asking me to examine mummies they had found. The second part turned out to be correct but the first, the quick and easy part, took seven years, with a move to the University of Pennsylvania, and field trips to Alaska and Egypt. The book is arranged in topical order. After beginning chapters reviewing the history and science of paleopathology and my introduction to the field, studies in Egypt and Alaska are followed by my involvement in a number of unusual projects. Figures and further details are readily available in the scientific literature, as listed in the Bibliography, which includes my various papers. The last chapter reports an ongoing project involving the University of Manchester’s KNH Centre for Biomedical Egyptology, UK, the Max Planck Institute for the Science of Human History, Germany, and the Department of Geography, Masaryk University, Czech Republic.

Chapter 1

WHY AND HOW WE EXAMINE MUMMIES Paleopathology is defined as the study of the evidence of disease in ancient human and animal remains. The field is of necessity multidisciplinary. The examination of mummified and skeletonized bodies requires the collaborative efforts of specialists from many fields, including physical and cultural anthropology, archeology, history, demography, epidemiology, genetics, pathology, orthopedics, radiology, obstetrics, hematology, parasitology, dentistry, orthodontics and others. When I began to study mummies, the actual full dissection of a mummy would take several days and was usually followed by a year or more of laboratory work, followed in turn by a comprehensive effort to focus the study on the interface of the physical, social, biological and medical sciences, with publication of the findings as an eventual result. With new technology available, such full dissections are now rarely performed and are replaced by selected biopsies under guidance by computerized tomographic (CT) scans. Disease and death are integral parts of the history not only of individuals but of whole populations as well. Pathogens, organic and inorganic factors causing disease, change over time and patterns of disease

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evolve just as do living organisms, including the hosts and vectors of disease. Paleopathologic studies, in adding the crucial dimension of time, are aimed at improving our understanding of the evolution of diseases and their role in human biologic and social history. The first usage and definition of the term paleopathology appears to have been by Shufeldt in 1892: “Paleopathology (Greek-paleo, ancient, and pathos, a suffering), the word used in the title of this paper is a term here proposed under which may be described all diseased or pathological conditions found fossilized in the remains of extinct or fossilized animals.” Sir Marc Armand Ruffer (1859-1917) is considered the father of modern paleopathology and his 1913 definition “the science of the diseases which can be demonstrated in human and animal remains of ancient times,” is the one generally accepted today. Ruffer, an English physician and bacteriologist, went to Egypt at the turn of the 20th century to recover his health after a bout of diphtheria. He became interested in the study of mummies and developed his eponymous solution for mummy rehydration. Sadly, Ruffer was lost when a ship he was on was torpedoed and sunk in the Mediterranean Sea during WW I. Many authors have speculated as to the role of disease in human evolution. The clearest example of the evolution of a disease is the relatively recent development in Africa of falciparum malaria. The clearing of land for agricultural use produced an environment favorable to a species of mosquito that happened to be a more efficient vector for Plasmodium falciparum. The result was an increase in this most severe type of malaria and a decrease in the other forms of the disease. The protective effect against falciparum malaria by selection for the sickle cell mutation in humans has also been carefully studied. There is evidence for considerable stability in some other host-parasite relationships. Similar tapeworm and roundworm infestations have been found in Egyptian mummies and modern Egyptians. There is also a significant degree of similarity or actual identity of a number of human and non-human primate infections despite millions of years of divergent evolution of the respective genera.

Why and How We Examine Mummies

3

Evaluation of the host-organism relationship over time requires more information on ancient disease patterns, which can be obtained from ancient pathologic material and several other sources. Epidemiological studies had been performed on cemetery material by Dr. Angel, but at present much of our concept of the distribution of disease in populations in the past is based on historic records. Examples are Egyptian medical papyri and studies of the role of epidemic diseases in the decimation of the indigenous populations after European colonization of the New World and Polynesia. We also have accounts of the great plagues of medieval Europe and epidemics in the more recent past. Works of art are another source that often gives information on disease. These include such diverse media as paintings, pottery effigies, figurines and religious statuary, and figures and faces on coins. The examination of skeletal material and mummies yields the most reliable paleopathologic information, although the study of ancient (and indeed modern) disease is not without its pitfalls. Skeletonization may be an erratic process and pathologic changes may be obscured or obliterated by the vagaries of preservation. In particular, acidic soil simply dissolves bones. Pseudopathologic changes can be produced by erosive forces or anthropophagic animals and most diseases leave little or no direct mark on the bones. Lines of arrested growth (Harris lines) in the long bones have been interpreted as evidence of childhood illness, as an index of morbidity in a given population, modern or ancient. Some questions have been raised as to the validity of applying this technique to ancient populations, as Harris lines have been shown to disappear later in life. They are also seen after immunization procedures, suggesting that they could result from trivial subclinical infections. Mummies, defined as bodies preserved either naturally (by freezing, drying, or tanning), or artificially, hold a great potential for paleopathologic examination. The preservation of tissues postmortem is based on inactivation of proteolytic enzymes in invading bacteria and fungi and in the tissues themselves. In the modern laboratory this process is called fixation and is accomplished by immersion of the tissue in a liquid

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chemical fixative, usually some variant of formaldehyde. Occasionally tissue is quick frozen for certain studies, usually for rapid diagnosis in clinical situations. Fixation is rapid and results in good preservation, or at least the production of consistent artifacts, which can easily be ignored in everyday practice. In contrast, mummification is based on enzyme inactivation by heat or cold, usually combined with desiccation. The process is often erratic and anything but rapid, classical sources describing a 70 day period of mummification in ancient Egypt. The inevitable result is a degree of tissue destruction, autolysis, which may obscure pathologic change or even underlying tissue structure. Loss of the features of color and consistency so useful to pathologists in examining fresh tissue limits the interpretation of gross pathologic change but the tissues can be rehydrated and sections prepared for microscopic examination. A few nineteenth century investigators soaked mummified tissue in caustic potash for rehydration, checking the process at the desired state with formalin. Formalin coagulates the proteins in tissues, thus deactivating the enzymes which are responsible for tissue breakdown. Rehydration of desiccated tissue is now based on the use of the solution developed by Ruffer in the course of his early studies of Egyptian mummies. During the first 2 decades of the 20th century, Ruffer developed his rehydrating solution, which is still in use. The solution is 50 parts water, 30 parts absolute alcohol and 20 parts 5% sodium carbonate. This solution is most conveniently prepared by dissolving 0.6 gr. of sodium carbonate in 42 ml. of water and adding 18 ml. of absolute (100%) alcohol. Ruffer’s original technique involved removing one third of the solution for three consecutive days and adding an equivalent amount of absolute alcohol, finally replacing all of the solution with absolute alcohol for three more days. Williams, in the 1920’s, used weak formalin as a rehydrating agent, with acceptable results. In the 1960s, Allison simplified Ruffer’s technique by simply immersing the tissue in Ruffer’s solution till they were fully rehydrated to visual inspection (usually 24-48 hours was sufficient). The tissue is then fixed in alcohol and processed. This is the procedure I use and it works well. Elimination of the changes of solution greatly decreases the trauma to which these delicate tissues are subjected.

Why and How We Examine Mummies

5

If the tissues dissolve in the solution it is because they are completely contaminated by bacteria. The solution always develops a yellow or dark brown turbidity. The KNH Centre for Biomedical Egyptology at the University of Manchester uses “washing up soap” with good results. The tissue can then be processed in the same fashion as normal tissues are. Rehydrated specimens are fixed in absolute alcohol for one day, embedded in paraffin and sectioned and stained according to standard histologic procedures. A variety of special stains can be used to demonstrate specific features of the tissues. In general, the connective tissue and any foreign elements, such as pigments, bacteria, or parasites are best preserved, while epithelial tissues fare less well. Thus the connective tissues stains are those used most. These include the Masson trichrome, which stains muscle red and fibrous tissue blue (or green), and the phosphotungstic acid hematoxylin (PTAH), for the cross striations of muscles. The standard hematoxylin and eosin (H&E), which stains nuclei blue and cytoplasm pink, is useful only in a very general sense. (Pathologists say, “We like to make what we don’t know a different color”). In addition to light microscopy, mummified tissues (and bones) can be studied by a number of other techniques, including scanning and transmission electron microscopy, chemical analyses, and paleoserology (examination for blood type and antibodies against specific disease organisms). Microbiological studies have not been useful, as viable pathogens, disease causing organisms, have not been cultured from paleopathologic material, although organisms can be recognized histologically, including viruses on electron microscopy. Any organisms cultured have always been postmortem contaminants. Some other techniques that have been applied to rehydrated tissue include plastic embedding of bone specimens, which would otherwise have to be decalcified, and electron microscopy (EM). There are two types of EM. Scanning electron microscopy can be done on tissue sections, by removing the coverslip and plating the tissue with gold, resulting in a three dimensional image. Transmission electron microscopy involves a special fixative and processing, and gives higher magnification with a clearer cross

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sectional picture of the internal structure of cells and potentially of any intracellular viruses. Dating of biological materials, human or nonhuman, is often of importance in dating an archeologic site, either independently or in correlation with conventional archeologic techniques such as the evaluation of pottery, hieroglyphic texts or other artifacts or historical records. In paleopathology, dating is essential in providing an historical context for the evaluation of the significance of any disease processes detected. Radiocarbon dating is the “gold standard,” but a variety of other techniques are applicable. These include amino acid racemisation, which is temperature dependent, electron spin resonance, and ancillary techniques such as dendrochronology, mummification styles and tattoos. Radiocarbon or 14C dating is based on the natural occurrence of carbon in 3 isotopic forms, 12C, 13C, and 14C, in the ratio of 100: 1: 0. 01. 12C and 13 C are stable while 14C decays at 1%/80 years, with the supply being replenished by cosmic radiation in the upper atmosphere. The half-life is 5,730 +/- years, with eventual degradation to nitrogen. Living organisms have a radiocarbon content equal to that of the atmosphere, as 14C is incorporated into plants by photosynthesis and then ingested by animals. After death, radiocarbon activity decreases at a predictable rate, based on the half-life, and measurement provides the time since death. Deviations in atmospheric radiocarbon of up to 2% are known and can be corrected for. Solutions of amino acids, the building blocks of proteins, have the property of rotating polarized light, to the right, the D (dextrorotary) form or to the left, the L (levorotary) form. The D and L forms are referred to as enantiomers and amino acid racemisation is based on the occurrence in nature of D and L enantiomers in a 50/50 ratio. Animals absorb only the L form, which then racemises in the body back towards the 50/50 ratio. There is a racemisation constant for each amino acid. The process is also temperature dependent, so environmental data is needed for accuracy. Enantiomeric ratios and amino acid compositions have been studied in meteorites, Precambrian rocks, and in simulation experiments of primitive earth conditions.

Why and How We Examine Mummies

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During the past several decades, amino acid racemisation dating of fossil materials has emerged as a promising new technique with applications in oceanography, geology, paleontology, and archaeology. The method is based on the fact that the L-amino acids found in the proteins of living organisms undergo a slow process of spontaneous chemical racemisation following burial. The rate of the racemisation reaction depends on the average temperature to which the fossil has been exposed since deposition. For most lower- and mid-latitude continental environments, the rate of racemisation is sufficiently rapid to date materials which are Holocene to Middle Pleistocene in age. Although the limit of radiocarbon dating is effectively 50,000 years, amino acid racemisation can provide the means of dating much older fossil bone. Mid-Pleistocene to recent times mark an especially critical period for the evolution of hominids biologically and culturally, a period for which no other bone dating technique presently exists. Furthermore, racemisation analyses require 5-10 grams of bone, whereas standard radiocarbon techniques, which are destructive, may need 100-200 times that amount. When fossil remains are very scanty or are anthropologically too valuable to be totally sacrificed for a date, and until accelerator radiocarbon dating has demonstrated accuracy beyond about 50,000 years, the racemisation technique could usefully be applied, once a calibration has been determined for the site. The most insidious problem facing amino acid racemisation dating, and radiocarbon dating as well, is the preservation state of the sample. It is clear that a cascade of errors originates with an incorrect calibration. The challenge to the racemisation method in the coming years is to develop criteria for assessing the preservation status of a bone in order to apply the chronometric analysis successfully. Dating with electron spin resonance (ESR) has now been established as a new method in chronology science. This technique is based on the induction of increased spin of electrons by cosmic radiation, the dose of which is time dependent. Very highly specialized equipment is needed for the quantification of electron spin. ESR dating for certain objects is not as accurate as 14C dating, because ESR dating has started so recently and at

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present there is very little reported work available. Collaborative studies between physicists (or chemists) and archaeologists or geologists will make this dating technique complementary to 14C dating by covering the open time range between the old limit of 14C dating (50,000 years) and the lower limit of Potassium-Argon dating (used for dating rocks). Variations in mummification practices are of some use in date determination of Egyptian mummies. The Egyptian practice of artificial mummification developed from the natural preservation of unclothed bodies buried in the hot, dry sands of the desert in preDynastic times. These bodies were not embalmed but simply wrapped in linen, hides or reed mats and placed in a flexed position in a shallow grave in the desert. The excellent preservation of these bodies may have had a role in the development of the belief in life after death and, indeed, small objects, apparently intended to serve the dead, are often found in the graves. By the beginning of the Dynastic Period, about 3,100 BCE, it had become customary to provide the deceased with food and funerary furniture. The graves became larger and tombs, both above and below ground, were developed, all of which served to separate the bodies from the desiccating action of the sand and allowed decomposition. It became necessary to develop artificial techniques of mummification, based on removal of the fluid components of the body. The preserved body, considered the dwelling place for the deceased individual’s eternal spiritual elements, was an essential component of the Egyptian theological belief system. Deceased Egyptians were mummified until the Christian era, (200-641 CE). Initially restricted to royalty, mummification became a more general practice, with a gradual refinement in technique over the millennia (although in all periods the poor were less carefully mummified). During the First and Second Dynasties (3,100-2,686 BCE), bodies were closely wrapped in linen bandages, eventually with separate bandaging of the extremities, and placed in wooden coffins. It was soon found that these bodies decomposed and that evisceration was necessary. As early as the Old Kingdom’s Third Dynasty, the viscera were removed through an incision in the left flank. Desiccation was attempted by

Why and How We Examine Mummies

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immersion in a natron solution (primarily sodium carbonate and sodium chloride), but this technique is relatively ineffective. Old Kingdom (2,6862,161 BCE) and Middle Kingdom (2,050-1,750 BCE) mummies were not thoroughly desiccated and have mostly crumbled to dust inside their wrappings. It was not until Dynasty XVIII (1,567 BCE) that the body was completely desiccated, by the heat of either the sun or a fire, after a period of maceration in dry natron. By this time, the brain was also removed, by fracturing the ethmoid or sphenoid bone, and the use of resin became common. The resin, applied in a hot liquid state into the thoracic and abdominal cavities and over the entire body, penetrated throughout the entire body. The resin is usually found by modern investigators to have dried into a glasslike substance, but I have occasionally found it in a semisolid tarry state, confirming that it had been applied as a liquid. The viscera were traditionally divided into four parts, the liver, stomach, lungs and intestine, and embalmed separately. The brain was discarded as the ancient Egyptians were unaware of its function. The heart was left in place as part of the funerary ritual. It was believed to be balanced by the gods against maat (the feather of truth). If heavy with sin, the unfortunate deceased was doomed to the lowest level of the afterworld, an unpleasant place populated by monsters such as three headed crocodiles. The kidneys were left in place, probably because they were in the inaccessible retroperitoneal space. The embalmed organs were placed either in four Canopic jars, a compartmented chest, or miniature coffins. Old Kingdom jars are described as roughly shaped limestone jars with a convex lid. By the Middle Kingdom, the jars had acquired human heads. During the new Kingdom, one jar had a human head and the other three were capped by the head of a falcon, jackal and baboon. After Dynasty XXI, the viscera were returned to the body in linen parcels but empty jars continued to be associated with some mummies. By the Roman period, bodies were no longer eviscerated, being dried with the organs in place, but solid, dummy “jars” were still provided. Another innovation of Dynasty XXI was subcutaneous packing of the trunk and limbs with mud, sand and sawdust, in an attempt to more closely approximate the natural contours of the body. The use of resin to coat the

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body and wrappings was introduced sometime during the New Kingdom and continued to be used on some mummies through the Roman Period. After desiccation and treatment of the viscera, the remaining space in the body cavities was packed with sand, sawdust and linen. The flank incision was brought together, occasionally sutured, and covered with a plate of wax, metal or gilded wood inscribed with the Horus-eye (as a protective amulet). Elaborate bandaging completed the process of mummification. The actual techniques of mummification were described in antiquity by Herodotus and Diodorus Siculus. Three types of mummification are described. The most expensive of these procedures involved removal of the brain and viscera and desiccation of the body by packing in dry natron for a period of 70 days. The dry body was then wrapped in linen bandages, coated in resin, and placed in a coffin. The second method was less expensive and utilized dissolution of the viscera in situ with cedar oil injected through the anus and retained for the 70-day period of desiccation. The oil was then removed, bringing with it the viscera. The body was returned to the family without wrapping. The third type of mummification was the least expensive, simply involving an intestinal purge followed by desiccation. Modern recreation of the full mummification technique (Chapter 8) has shown it to be an effective preservative of the body. The histologic appearance of this mummy was quite similar to that of ancient bodies, indicating that there is little further deterioration of the desiccated tissues. While these three different techniques were certainly used in ancient Egypt, it has become clear that the style of mummification was based on economic factors, particularly the status and wealth of the family of the deceased. Mummies examined by the Paleopathology Association and its individual members have shown classical evisceration through a left lower quadrant incision with organ parcels placed in the body, or organs left in situ and decomposed or preserved. Other mummies have shown packing of the abdomen with linens through the vagina and rectum, with the organs compressed against the diaphragm, or evisceration through the anus with packing of the empty body cavities with sawdust (Chapter 6). These

Why and How We Examine Mummies

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studies have led me to believe that variations in mummification styles provide only very general guidelines for the separation of mummies from the predynastic period and the Old, Middle and early and late New Kingdoms. The examination of tattoos has been useful in the estimation of dating for mummies. Patterns and artistic motifs found in tattoos can be compared to those found in artifacts of known date. In the case of more recent mummies, comparison may be to historical records, such as descriptions by early explorers, or to drawings, photographs, or even living individuals. It must be stressed that the value of the study of tattoos is limited by the accuracy of dating of the comparative material. In the few cases where the technique has been applicable, the result has been an approximate date only. The pigment used for ancient tattoos was generally soot, resulting in a dark blue or black tattoo, easily seen in the living but difficult to discern in the skin of a mummy, which has usually turned dark brown. As blue objects are darkened when photographed with infrared film, the use of infrared photography has proven invaluable in the detection and evaluation of tattoos in mummies. Tattoos have rarely been found in Egyptian mummies, so the use of tattoos for dating had been confined to northern climates, where preserved bodies with tattoos have been found. Central Siberia has yielded up frozen mummies of Scythians, one of the great tribes of nomadic horsemen of the steppes of Eurasia. The mummies of tribal chiefs, interred in burial mounds over 2,000 years ago, have been preserved by freezing. The burial chambers are deep pits covered by earth, logs and boulders, which remained natural refrigerators over the short Siberian summers, preserving the bodies of the chiefs and their entombed entourage and trappings. The bodies had been eviscerated and embalmed and, despite being disturbed by the inevitable tomb robbers, the skin remained in excellent condition. There were many elaborate animal tattoos. Fortunately, other areas in the mounds, containing the chiefs’ horses, yielded a treasure trove of artifacts, again decorated in a similar style. The matching of the tattoos indicated that the bodies were indeed the original occupants of the tombs.

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(Egyptian mummies are often in found to be in reused, older coffins.) As the tombs were partially constructed of wood, dendrochronologic studies could establish a relative age range for the Siberian tombs of about 500 years. Absolute dating by radiocarbon seems to have been less specific, with a range from the 7th century BCE to the 1st century CE. Stylistic grounds place the date at the fifth to the third century BCE. The other studies involving tattoos as an aid to dating have been on Eskimo mummies. In 1971, beach erosion on St. Lawrence Island, Alaska, exposed the frozen, naturally mummified body of a middle-aged Eskimo woman. An autopsy revealed death to have been due to suffocation after accidental burial, probably in a house cave-in or landslide (Chapter 12). Soft tissue from the body was radiocarbon-dated to the 4th century CE, placing the body in the Old Bering Sea phase on St. Lawrence Island, about CE 200-500. During thawing of the body, tattooing of the right arm was noted. Tattoos on the left arm were barely visible, and infrared photography was found to be necessary in order to decipher the tattoos completely. The tattooing was seen on the dorsal aspect of the forearms, hands and fingers. The basic pattern was one of alternating solid lines and rows of dots on the forearms and dots on the fingers. On the back of the hands and the left arm was a “flanged heart” design attached to a solid line. Further examination of the body failed to reveal any other tattoos, although it was customary on St. Lawrence Island until recently for Eskimo women to have tattoos on the chin and/or cheeks. The practice was described by Otto Geist in 1928 Otto Geist in a letter to Dr. Charles Bunnell dated 1928, a portion of which follows: “Some of the St. Lawrence Island Eskimo women and girls have beautifully executed tattoo marks. These are made free hand although sometimes an outline is traced before the tattooing takes place. The pigment is made from the soot of seal oil lamps which is taken from the bottom of tea kettles or similar containers used to boil meat and other food over the open flame. The soot is mixed with urine, often that of an older woman, and applied with steel needles. Two methods of tattooing are practiced. One method is to draw a string of sinew or other thread through

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the eye of the needle. The thread is then soaked thoroughly in the liquid pigment and drawn through the skin as the needle is inserted and pushed under the skin for a distance of about a thirty-second of an inch when the point is again pierced through the skin. A small space is left without tattooing before the process is again repeated. The other method is to prick the skin with the needle which is dipped in the pigment each time.” Designs that are similar to the flanged hearts have also been seen on artifacts from the Old Bering Sea phase. An Old Bering Sea phase gorgetlike ornament (a decorated collar) has been identified with a bar and dot motif very similar to the tattooing design found on the arms. Other artifacts, including an okvik, a dart socket piece from Little Diomede Island show a similar design; the piece is illustrated in Collins’ Archeology of St. Lawrence Island, Alaska. The most recent attempted application of the study of tattoos to dating was in the examination of a group of desiccated Eskimo bodies found near the abandoned settlement of Qilakitsoq in northwestern Greenland. The group was composed of two children and six adult women. The faces of five of the women showed tattoos on their foreheads. Four were also tattooed on the cheeks and three on the chin. Only the youngest woman children showed no tattoos. The find was radiocarbon dated at CE 1,475 +/- 50 years. Unlike the St. Lawrence Island mummy, the tattoos of the Greenland Eskimos were of no real importance in dating the find. Identical tattoos on Eskimo female faces have also been recognized on one of the earliest known European drawings of Eskimos, dating to CE 1,655, as well as on seventeenth century paintings. Tattooing persisted in Greenland till the middle of the 18th century and even later in the southern and eastern parts of the country. This 400 year time span for Eskimo artistic motifs makes tattoos of little value in dating human remains from this geographic area. In summary, under rare circumstances bodies may be preserved with intact tattoos, which may be helpful in dating. Similarity of motifs between tattoos and artifacts can provide some reassurance that both are from the same general time period. The utility of this approach is limited by the

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accuracy of the dating of the artifacts and by the innate conservatism of aboriginal art and motifs for hundreds or thousands of years. Age determination is another important facet of the study of human remains, allowing the construction of population profiles and the development of a paleoepidemiologic approach to a variety of topics. At the individual level, many diseases occur in specific age ranges and age determination can be a critical factor in differential diagnosis, particularly with regard to bone diseases. In contrast to dating, no one aging technique is best. Techniques used include gross evaluation of the skeleton and viscera, hand-wrist radiographs, bone histology, dental changes and, in special cases, amino acid racemisation. Age estimation can be done from bone or soft tissue, including mummified remains. The expected precision of age-related variation in mummified bodies is far less than that obtained from the skeletal system but a rough estimate as early, middle or late adult stage can be made, usually based on the degree of atherosclerosis. Estimation of age at death from the skeleton is of concern to many scientists. The archaeologist uses this valuable information as an integral part of his reconstruction of a prehistoric society. For the paleodemographer and paleopathologist, knowledge of age at death is vital to determine population composition, mortality, morbidity and fertility. Furthermore, the need to identify unknown individuals in modern forensic cases has made the estimation of age at death important for practical purposes as well. The aging process is continuous from the time of conception, operating under three general states of growth, maintenance and atrophy. The growth state is characterized by the beginning of ossification and ends with the union of bony epiphyses and eruption of adult teeth. Dentition is usually complete by 12 years (except the third molars), while epiphyseal fusion and union continue into the third decade of life. During the growth stage, rapid and consistent changes are easily observed with the naked eye. However, the maintenance phase of aging commencing at maturity is characterized by changes that are much more

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subtle and varied, and thus harder to detect. In old age (over 55), atrophic changes such as osteoporosis usually becomes obvious. In the living body, maintenance implies the preservation of the status quo. Unlike growth, the maintenance state is much more individualized. There is no precisely timed, universal sequence of events. Two individuals might attain similar age-related morphologies at different periods. Furthermore, interpersonal and intrapersonal variations increase with age, both externally and internally. The challenge for the scientist is to be able to develop methods and find sites within the living system that could enable one to predict the effects of external factors and to estimate age more reliably. There are basically three visual methods for the evaluation of agerelated skeletal changes: (1) direct observations of bone morphologically; (2) observations of bone radiographically; and (3) histologic examination of bone. Throughout life the skeleton shows changes of physiological (or biological) age, as opposed to chronological age, or age at death in years. For demographic, health and historical purposes in archaeological material, and for legal identification purposes in forensic skeletons, the latter is needed. Complicating this assessment is the fact that humans grow through childhood, adolescence and adulthood at their own pace and own way. Most people age in a standard pattern but age more in some systems than in others. In Western society, the cardiovascular-renal system ages faster, especially in modern American males, than it did in the past. This effect is likely to be a result of changes in nutrition, pollution (including inhaling cigarette smoke) and even increased levels of tension. In the infant to sub-adult range, gross examination of the size and ossification of bones provides reliable means of age estimation. In adults, age indicators span broader ranges. There are new and reliable data from modern autopsy samples for the following skeletal areas: the sutures of the skull vault; the costochondral junction of the ribs; the epiphyses of the medial clavicle and the anterior iliac crest; and the pubic symphysial face in young males. The last is less reliable for females, and a variety of age indicators should be used for adults.

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Bone structure on the histologic level includes primary and secondary osteons and the lamellar bone. Changes in these structures are correlated with increasing age. Recorded are the number of secondary osteons, the average number of lamellae per osteon and the average diameter of the Haversian canals. A core is taken, usually from the femoral shaft and examined for cortical thickness, weight and mineral content, along with many other variables, and a formula has been developed for age. This approach is better for older adults, in whom gross morphology is not as effective. For living individuals who are not fully mature, radiologic examination of the hand and wrist, including the distal ends of the radius and ulna, is a standard tool for estimating biological age. Maturation involves changes in function and development, as well as growth or increase in size. An X-ray that shows the presence and form of calcification of the carpals and the epiphyses of the long bones of the hand and wrist contains a large number of sites that can serve as markers of maturation. These bones gradually become calcified in the course of maturation. Ultimately, the epiphyses of the long bones fuse with their shafts, and linear growth is no longer possible. Although there is some variation in both the timing and the sequence of developmental changes, methods have been devised that evaluate the portion of this process that has been completed. In any decedent in whom the wrist is not disarticulated (a mummy, for example) an X-ray can be obtained and a bone age derived by one of the techniques described below. Attempts to derive a bone age directly from skeletal material where the bones of the hand and wrist have become disarticulated are inadvisable except by the most experienced. Disarticulation alters the orientation of the carpals, which introduces a source of error in observing their shape, and makes highly likely the loss of the tiny bits of bone that are unfused epiphyses. However, for material in which an articulated wrist and hand remain, the estimation of biological age from a standard hand-wrist radiograph should be not only feasible but of appreciable utility. Under rare circumstances amino acid racemisation can be applied to age determination. The racemisation reactions typically have half-lives on

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the order of 104 to 106 years and the temperature dependence of the reaction rate implies that measurable amounts of racemisation might be occurring on a much shorter time scale. Mammals and birds maintain body temperatures in the range of 37 to 39 degrees C. Many homeotherms, including humans, also live for many decades. In a metabolically stable protein, i.e. one that is synthesized early in development and not broken down and resynthesized during the homeotherm’s life span, one expects to find small amounts of D-enantiomer accumulating by looking at a relatively rapidly racemising amino acid such as aspartic acid. The Amino Acid Dating Laboratory at the Scripps Institution of Oceanography, University of California, has studied the extent of aspartic acid racemisation in human structural proteins. Studies have included several calcified dental tissues, the ocular lens, connective tissues and neural tissues. D-aspartic acid accumulates in these proteins at rates of 0.02 to 0.14 per cent per year. These results are being applied in gerontology, physical anthropology and paleopathology, forensic sciences, wildlife biology and game management. Aspartic acid racemisation in structural proteins of warm blooded animals (homeotherms), including humans, provides a promising new technique for measuring biological age or age at death. At present, either tooth dentine or the ocular lens nucleus is the sample of choice for enantiomeric analyses and age calculations. An age determination based on dentine should fall within 10 per cent of the organism’s true age. Dentine measurements have been applied to a variety of marine and terrestrial mammals and to humans in order to resolve problems in wildlife biology, fisheries management, paleoanthropology and forensic science. Aspartic acid racemisation may also play some role in functional deterioration during the aging process. Teeth are very useful for determining the age at death of archaeologically derived skeletal material or the remains of individuals who have been burned, drowned, desiccated or decomposed to the extent where normal means of identification are no longer possible. Teeth are hard, durable do not melt or burn, and change from approximately 20 weeks in utero until the last tooth is lost or its owner dies. The changes

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used by archaeologists to determine age-at-death can be divided into: developmental changes in the formation and eruption of deciduous and permanent teeth; degenerative changes, which are the results of tooth usage and dental pathologies that occur during the functional life of the tooth; and histologic changes, which are related to the age of the tooth, but seen only in microscopic section. Developmental methods seem to work best. Despite more than a century of research in forensic odontology, it is not possible to age an individual precisely after the crowns of the teeth have finished developing (although analysis of annulation rings in cementum holds the promise of rectifying this situation). For this reason, dental aging should always be accompanied by other skeletal methods whenever possible. The basic features for sex determination are robusticity of such areas as the forehead, chin, eyebrows, mastoid processes and muscles attachments. The angle of the pelvic sciatic notch, narrow for males, wide for females, is a useful criterion. Chemical analysis of bone is used primarily for dietary reconstruction. Determination of stable isotopes rations for carbon and nitrogen have been used in determining the relative levels of meat and vegetable matter in ancient diets, and for determining whether food sources were marine or terrestrial. Trace elements are also studied. Strontium can also give us an idea of how much meat was eaten, and lead levels indicate either domestic or industrial exposure to this toxic material. For example, it has been found in skeletons recovered from southern US plantations the owners had much higher lead levels that their slaves, due to lead used in pewter tableware. The analysis of bones (and mummified material) for ancient DNA (aDNA) has received much recent interest. Although there are technical problems related to the survival of aDNA and contamination by modern DNA, in the field or laboratory, potential applications include the determination of genetic relationships, sex determination and paleopathology.

Chapter 2

THE HISTORY OF MUMMY PALEOPATHOLOGY The history of paleopathology can be conveniently divided into several time periods, starting with a preliminary period in the United States from 1822 to 1865. Dr. John Collins Warren was a Boston surgeon and anatomist who was one of the pioneers in the use of ether anesthesia. With an interest in phrenology, a theory that skull shape was linked to intelligence and personality, he studied American Indian crania. He described artificial cranial deformation in a book published in 1822. However, he did not discuss spontaneous disease, nor did he distinguish between pre- and post-Columbian aborigines. In 1839 Samuel G. Morton published Crania Americana, with illustrations of pathologic skulls, one showing an anemia related condition now called porotic hyperostosis. Although Morton had training in pathology, he limited himself to ethnographic remarks. A number of 19th century pathologists who worked in paleontology, archeology or ethnology neglected paleopathology (including Thomas Hodgkin). This tradition may have been one of the factors that have put human paleopathology in the realm of anthropology and away from pathology. The next period was from 1865-1900. Joseph Jones was the first investigator of pre-Columbian human remains to focus on disease. He

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conducted extensive excavations in the Southeastern U.S. and found bones that he considered to be syphilitic and truly pre-Columbian. His descriptions remain perfectly adequate for diagnosis. It is apparent that he made thin sections and examined them with a hand lens but did not use the microscope. He probably had a great deal of experience with syphilis, being in forensic medicine in the southern United States, where there was a high incidence of the disease at that time. The remainder of the 19th century course of paleopathology was dominated by activities at the Smithsonian Institution (founded in 1846), the Army Medical Museum (1862), now relocated to the Armed Forces Institute of Pathology (AFIP), and the Peabody Museum at Harvard (1866). Jeffries Wyman and Frederic Putnam, early curators of the Peabody, produced some papers on paleopathology and Putnam in particular became embroiled in a conflict with Jones over the diagnosis of syphilis in the skeletons Jones had described. William Whitney of the Harvard Anatomical Museum wrote somewhat more extensively on skeletal paleopathology. The Smithsonian and the Army Medical Museum were neighbors of the Washington Mall and in the late 19th century staff members of both institutions interchanged and studied material, but paleopathology was not a major concern of either place. At this time in Europe a controversy arose when Rudolf Virchow, the German pathologist, anthropologist, and politician questioned the authenticity of the Neander Valley specimen, suggesting that the Neanderthal remains were those of an abnormal modern man, suffering from either rickets or syphilis. The next period, from 1900-1935, began with the appointment of Aleš Hrdlička to the directorship of the Division of Physical Anthropology of the reorganized U.S. National Museum (the Smithsonian). Hrdlička was an M.D. who devoted his entire career to physical anthropology. He made some contributions to paleopathology, particularly in describing what he called “symmetrical osteoporosis” (now porotic hyperostosis). He noted that these lesions were probably representative of a systemic disorder. He also wrote a number of articles, built one of the world’s great collections

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and contributed to the training of many people, notable his successor, T. Dale Stewart. During this period X-rays began to be used for examining paleopathologic material. Flinders Petrie examined prehistoric Egyptian bones in 1897, but the technique was little used till the work of Moodie in the 1930’s, and is only now beginning to be fully utilized, with the advent of computed tomographic (CT) scanning. The first of the truly modern paleopathologists was Sir Marc Armand Ruffer (1859-1917), as noted in the preceding chapter. Ruffer followed up the descriptive studies of the English anatomist Grafton Elliot Smith by developing the rehydration technique that is still in use for preparing microscopic sections of mummies. He made a number of important diagnostic contributions to the field. The first full length book on paleopathology was written by Roy L. Moodie, an American anatomist. His book covers man, lower vertebrates, plants, etc. and contains many errors, mostly related to the theories of the early century. Moodie also edited Ruffer’s collected papers and published other books and papers in the field. After Hrdlička’s death in 1943 the leading American physical anthropologist was Ernest Hooten. He is remarkable in paleopathology for his description of the Pecos Pueblo material, and for his efforts to reconstruct the age distributions of populations, beginning the fields of paleodemography and paleoepidemiology. The period from 1950 to 1970 was characterized in the United States by only sporadic contributions from individual physicians and in Great Britain by the work of Don Brothwell and A.T. Sandison, who published Diseases in Antiquity in 1967. The major problem during this period was finding a home for paleopathology. Pathology departments, organizations and their periodicals showed little interest in the field. There was some interest by medical historians and anthropologists over this period, but the field was actually revitalized in the 1970’s by the activities of three groups. The Paleopathology Association (PPA) was founded in Detroit in 1973 by Aidan and Eve Cockburn and 12 charter members, including myself. The origin of the PPA must start with Aidan and Eve Cockburn. In 1971

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Eve had a conversation with William H. Peck, Curator of Ancient Art at the Detroit Institute of Arts (DIA) about a projected trip to Egypt by Aidan, an epidemiologist with an interest in the evolution of disease, to investigate the possibility of research on mummies. “Has Aidan ever examined a mummy before?” “No”. “Would he like to practice on one of those we have in storage in the basement?” Eve and Aidan, Dr. Peck, Dr. Robin Barraco and Dr. Theodore A. Reyman gathered at the DIA and the dissection was done using a naval surgeon’s kit that according to legend had been used to operate on the future King George VI of England in WW I. Discussions regarding the formation of a paleopathology association were held at the 1971 AAPA meeting in Boston. The next year I assembled a group of 16 physicians, anthropologists, archeologists and other scientists at the Pennsylvania University Museum for a time travel into the human body, specifically to examine the mummy of an unknown ancient Egyptian man. He was dubbed PUM I, followed by PUMs II, III and IV (Chapter 6). PUM I was found to be a skeleton with some attached dry skin and muscle on the legs and trunk. Most of the tissues were poorly preserved but skin from the upper inner thigh showed small blister-like spaces filled with the remnants of inflammatory cells, diagnostic of a rare disease, subcorneal pustular dermatosis. First described by Drs. Sneddon and Wilkinson in 1956, this skin disease has been linked to more serious disorders. Like many diseases, it must certainly antedate its first clinical description, in this case by almost 3,000 years. That group of 16 became the charter members of the PPA with Aidan as the first Chairman. The Paleopathology Newsletter (PPNL) #1, edited by Eve, was published in March, 1973, barely two months after the examination of PUM II in Detroit. The first annual meeting of the PPA was held in 1974 at Amherst, MA, as part of the annual American Association of Physical Anthropology (AAPA) meeting. This chapter follows the careers of the 16 charter members, starting with their positions and areas of interest at that time and also covers the contributions of a few of the outstanding individuals who came on board later. I apologize for any who I

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have missed and for omitting the inclusion of a review of the numerous European, South American and other branches and meetings. Aidan Cockburn, MD, Detroit, MI, USA was a Research Associate, Smithsonian Institution and Director of Medical and Drug Abuse Clinics, City of Detroit. He was born in 1912 in northern England to a seafaring family. His father was killed at sea in 1918 and a more distant relative was Admiral Sir George Cockburn, known for the burning of Washington, DC in the War of 1812 and, on a kinder note, the abolition of flogging in the Royal Navy. After earning medical degrees from the University of Durham and training in Public Health, Aidan was active in civil defense during the Battle of Britain and then served in West Africa, Egypt and Palestine. He became interested in animal diseases and zoonoses as Assistant Superintendent at the London Zoo, initiating his study of the evolution and history of disease. Moving to the US, he spent six years with the United States Public Health Service and then joined the World Health Organization as Advisor to the Government of Ceylon (now Sri Lanka) and East Pakistan (now Bangladesh), dealing with huge smallpox and cholera epidemics. In 1971 he began the study of mummies in the US, leading to the development of our Association. In a 1978 JAMA article, Aidan clearly stated the raison d’etre for the study of paleopathology: “Those who confine their research entirely to diseases as they exist at the present moment are operating in a two-dimensional plane; paleopathology adds a third dimension. It is like the difference between monocular and binocular vision.” He was a wonderful organizer, a lover of scientific truth who combined strong purpose with a playful, sometime sarcastic wit, and a knack for having fun with his new ideas. In 1980 Cambridge University Press published Aidan’s third book, Mummies, Disease, and Ancient Cultures, which in the following year received an award from the American Medical Writers Association. Aidan passed away in September 1981 and Eve accepted the award for him one week after his death. In the 1979 meeting, Aidan had proposed that the PPA needed to develop a formal structure. The President’s motion, ahead of its time, was unanimously voted down, the members preferring the existing “highly

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productive confusion”. In the 1980s, with the loss of both Cockburns, the Association progressed to the election of a group of officers, with Don Ortner as President. Eve Cockburn had been writing on technical subjects for lay readers. Married to Aidan for 36 years, she shared his far traveling life, developed a syndicated column on health that ran in 55 newspapers in the Far East and edited a magazine for women in East Pakistan. She edited the PPNL for 26 years. Overseeing the growth of the PPA for 20 years after Aidan’s death, Eve made a point of recognizing and encouraging younger members. Retiring in 2000, Eve received an engraved crystal vase from the membership and a proclamation as the first “Past President” in recognition of her managing the PPA for more than a quarter century. She was virtually irreplaceable; after her death in 2003, it was found that five members were needed to do what Eve had done alone. Patrick D. Horne of the Dept. of Histopathology, Banting Institute, Toronto, Canada, performed pathology and electron microscope studies. In addition to his research work in paleopathology, Pat produced 5 year indices of the PPNL, served as Editor of the Annotated Bibliography and designed the Association’s globe-and-caduceus logo. He had many publications in paleopathology and medical fields, with first reports of a number of diseases in Egyptian mummies. One of his proudest moments was appearing as a model in an advertisement in Archeology magazine, listing the advantages of wearing a Tilley Hat in Egypt. My favorite story is when he noted lice in the scalp of the Aleutian mummy we were examining at Harvard University (Chapter 11). He took the scalp back to Canada with him for electron microscopy and had to explain what was in the plastic bag in his luggage at the Toronto airport. Having a receding hairline, he succeeded in convincing the authorities that it was his toupee! Pat passed away unexpectedly of a heart attack in 2008 while on vacation in Cuba. Theodore A. (Al) Reyman, MD chaired the Dept. of Pathology, Mt. Carmel Mercy Hospital, Detroit, MI. His memory is of the original five skulking around in the basement of the DIA doing our first mummy autopsy, not really knowing much at all but learning from scratch. Al

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subsequently participated in the dissection and histologic examination of the mummies from the University of Pennsylvania Museum (now known simply as the Penn Museum) and the Royal Ontario Museum (ROM), identifying the presence of schistosomiasis. Al is now enjoying retirement, although mourning the loss of his wife Donna in 2010. J. Lawrence Angel, PhD was Curator of Physical Anthropology, Smithsonian Institution. A physical anthropologist, he studied paleopathology, especially in bones showing evidence of disease as in relationship between malaria and sickle cell anemia. Larry earned his doctorate in anthropology with field work in Greece and Turkey. He was a gifted teacher, with an intensive course in forensic anthropology at the Smithsonian for many years. He applied his vast knowledge of anatomy and physical anthropology to forensic consultation for many law enforcement agencies, including the FBI. On a personal level, Larry was my first anthropology teacher and later became my mentor, friend, coauthor and scientific collaborator. His death in 1986 was a tragedy, as the hepatitis he contracted during a blood transfusion became preventable with the development of a suitable laboratory test a few years later. Robin Barraco was with the Dept. of Physiology, Wayne State University, Detroit, MI. Robin published on the preservation of proteins in mummified tissues, noting that mummies preserved by natron showed much less protein degradation than mummies preserved by freezing or air drying. He served as an advisor to the National Science Foundation, the National Institute of Mental Health, and many others. He died prematurely in 1996 at the age of 51. L.J. Bruce-Chwatt, PhD, (Professor of Tropical Hygiene, School of Hygiene and Tropical Medicine, London, identified fish parasites in an Egyptian mummified fish. He is now deceased. P.S. Gooch, PhD, Assistant Director, Commonwealth Institute of Helminthology, St. Albans, Herts, England maintained a register of all finds of helminthes (parasitic worms) from antiquity. He is now deceased. Peter K. Lewin, MD, a pediatrician and pathologist at the Hospital for Sick Children, Toronto, Canada, performed pathology and electron microscopy of mummy tissue. Peter combined his medical career as a

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pediatrician with a military career as a Colonel in the Canada Armed Forces Medical Services Branch and his studies in the paleopathology of Egyptian mummies. Peter published more than 100 scientific papers, including work on prions, the infectious particles responsible for illnesses such as mad cow disease. In the mid-1990s, Peter participated in an international project studying the frozen remains of miners who died of the 1918 Spanish flu on the Island of Spitzbergen. My well rounded friend was honorary physician to the Queen Mother during her 1975 Royal visit to Canada. Peter died in 2005 at the age of 69. George E. Lynn, PhD of the Dept. of Audiology, Wayne State Univ. of Medicine, Detroit, MI, studied temporal bones of ancient bodies, Egyptian and Peruvian. He noted lack of middle ear disease in Peruvians and speculated that they did not suffer from upper respiratory infections. George is now deceased. Dan F. Morse, PhD of the Dept. of Anthropology, Florida State University, Tallahassee, FL studied tuberculosis in Indian remains at the Nodena site in Arkansas and in ancient Egypt. He is now deceased. David O’Connor, PhD, an Egyptologist at the Penn Museum, lent the PUM mummies to the PPA for autopsy. David remains active in Egyptology, now at the Institute of Fine Arts of New York University. William H. Peck, PhD was Curator of Ancient Art, DIA, Detroit, MI, studying Egyptian art and archeology. After retiring from the DIA in 2004, he continued field work in Egypt until 2010 and is still teaching Egyptian art history as well as consulting for museums. His latest book is The Material World of Ancient Egypt, published by Cambridge University Press. A.T. Sandison, MD, Professor of Pathology, University of Glasgow, Scotland, was working in pathology and paleopathology in general. Andrew, a pioneer in the microscopy of mummified remains, was the joint editor with the late Don Brothwell of the seminal book, Diseases in Antiquity. He combined his paleopathology with a full career in clinical pathology as Consultant Pathologist to the Western Infirmary in Glasgow. Dr. Sandison passed away in 1982 and his obituary in the # 40 Newsletter

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has it just right; “he managed to keep our feet on the ground while exhorting us to look for the stars.” Eugen Strouhal, MD was Curator, Egyptology, Archeology, Anthropology, Mummy Studies, Naprstek Museum, section of the National Museum, Prague, Czechoslovakia, studying Egyptology, cultural features of mummies and embalming resins. Dr. Strouhal enjoyed a remarkable career in combining medicine, archeology, paleopathology and Egyptology. He survived several political upheavals in what is now the Czech Republic. As Professor of History of Medicine from 1995 at the Charles University Prague, he established paleopathology as part of the history of medicine program. He also taught physical and cultural anthropology at the West Bohemian University, in universities abroad and at the University of the Third Age for retired people wishing to continue life-long learning. He participated in numerous archeological expeditions to Egypt and Nubia. As Professor Emeritus since 2005 at Charles University, Prague, he continued to study skeletal and mummified remains covering the Old Kingdom through Roman and Christian periods and developed a course in paleopathology. As his career progressed, he became increasingly involved in paleopathology, participating in many of the PPA meetings and being one of our most faithful contributors to News from the Field. After recovering from a serious disease in 2004, he retired from the University but at 84 years of age he continued his research, focusing on the history of benign and malignant tumors. In 2006 Eugen received a Certificate of Honor in recognition of his being one of our charter members. He authored 18 books and published about 400 scientific articles, 276 news items from his scientific life and 251 reviews. His death in 2016 left me as the last charter member of the PPA still active in paleopathology. At the time of the founding of the PPA I was a pathologist with the Pathology Department, Hospital of the University of Pennsylvania, Philadelphia, PA and studying for my PhD in anthropology, completed in 1976 (Chapter 4). Two important figures who were not charter members were Don Ortner and Art Aufderheide.

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Donald J. Ortner, PhD, of the Dept. of Anthropology, Smithsonian Institution, Washington, DC, joined the PPA in 1975. Don and Bruce Ragsdale ran a series of workshops on skeletal paleopathology at our annual meetings, with such intriguing titles as “What’s in the Holes?” and “What’s in (or on) the Bumps”. Don also edited the series of Case Reports on Paleopathology and became our first elected president after the death of Aidan Cockburn. He served as Chairman of the Museum of Natural History’s Department of Anthropology and then as Acting Director of the Museum. One of our most distinguished members, he passed away in 2012. A complete list of his publications is on the PPA website. Arthur Aufderheide, MD, who joined the PPA in 1980, was a pathologist at the University of Minnesota Medical School at Duluth. He became a major figure in paleopathology, contributing many reports and articles to the literature, with a lengthy profile in the New Yorker magazine, as the “Mummy Doctor”. In addition to his medical work, he was a remarkable adventurer, participating in a snowmobile expedition to the North Pole in 1968. It was my pleasure to work closely with Art on studies in Alaska and Egypt. Art attended his last PPA meeting in 2011 at age 88 and continued working actively until his death in 2013. In his obituary for the Newsletter, I wrote, “Art Aufderheide and I were brothers in science. After I invited him to examine the frozen family of Barrow, he sometimes referred to me as his mentor but we learned from each other.” I had the privilege of working with him for almost 30 years but more than that we were the best of friends. I will miss his “Whoop-de-do” and have lost a wonderful collaborator. The association publishes the quarterly Paleopathology Newsletter and occasional monographs, meets each year in conjunction with the AAPA, and has met on occasion to examine a mummy. These studies, performed at a number of museums and medical centers in the United States and Canada, examining one Peruvian, one Aleutian, and six Egyptian mummies, went far toward improving the difficulties that were experienced in interpreting lesions in the past. A wide variety of new techniques have come into play. These include more sophisticated radiographic studies such as CT scanning, magnetic resonance imaging,

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electron and scanning electron microscopy, fluorescent antibody and other serologic techniques, neutron activation analysis and other chemical and microbiological techniques. From this small start, the organization has grown to an international scope, with hundreds of members. A second group, headed by Marvin Allison and Enrique Gerszten of the Pathology Department, Medical College of Virginia, Richmond, has conducted an extensive survey of Peruvian and Chilean mummies over the past decades. They have published many articles and monographs and the Paleopathology Club of the International Academy of Pathology has developed from this group. A seminar in paleopathology was held at the Smithsonian Institution from 1971-1974. This full length course, under the direction of J. Lawrence Angel and Don Ortner and with the cooperation of Lent Johnson, Walter Putschar and T.D. Stewart, provided a third major impetus in paleopathology. The seminar provided training for a number of people and was at least indirectly responsible for the publication of Ted Steinbok’s Paleopathological Diagnosis and Interpretation. The late Don Ortner wrote several paleopathology texts, as well as a registry of specimens in museums and lesions reported in the literature. The Armed Forces Institute of Pathology, also in Washington, has sponsored seminars in paleopathology. Interest in paleopathology continues to grow internationally. In the United Kingdom, the University of Manchester’s KNH Centre for Biomedical Egyptology is the first specifically designated research center for the investigation of Egyptian mummies in the world. Officially opened in 2003 by His Royal Highness, the Earl of Wessex, the Centre hosts a multidisciplinary team of researchers and students experienced in many different areas of science, medicine and Egyptology. The department is designed to bring together the many facets of Egyptological research, forming a major resource for this discipline. The University of Manchester’s involvement in this field can be traced back to 1907 when Dr. Margaret Murray undertook one of the earliest scientific unwrappings with the dissections of two Middle Kingdom mummies known as the Two Brothers in the Manchester Museum. This

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work was taken up again in 1972 with the development of the Manchester Mummy Project and the creation of a mummy team. The Centre represents the culmination of 32 years of research in this field at Manchester, under the initial direction of Professor Rosalie David, OBE. Although originally confined to the 17 mummies housed at the Manchester Museum, the project quickly expanded as other museums and institutions volunteered their mummies for scientific examination. After Dr. David’s semiretirement in 2011, and now under the direction of Dr. Anthony Freemont, the Centre has continued this new approach to understanding the civilization of ancient Egypt. The medical faculty at the University of Zurich houses the Institute of Evolutionary Medicine (IEM), founded by and under the direction of Dr. Frank Rühli. Researchers at the IEM analyze ancient biological material and associated data to improve our understanding of the evolution of modern human health and disease. This remarkable facility uses specialist scientific expertise, excellent infrastructure and state-of-the-art methods to work on such interdisciplinary research questions as “How does the past (for example the evolutionary origins of diseases) inform the present and the future?” In 1991 a 5,000 year old frozen body was found in the Alps. The body of the Iceman was initially believed to have been in Austria and I was invited to Innsbruck in 1992 to help determine the proper approach to the find. Although I and others were disappointed at that time, the decision was made to wait for improved methods before a full dissection of the body was attempted. That approach has turned out to be correct. A survey of the border determined that the body of the Iceman was in Italian territory and there is now a superb museum dedicated to this remarkable find, the South Tyrol Museum of Archaeology in Bolzano. The body, kept in a frozen state, and the associated artifacts have generated significant research, including determination of his cause of death, as well as generating insight into Copper Age Europe. Since 1992, the international community of mummy researchers meets every 3 to 4 years at the World Congress on Mummy Studies. As evidence of the growing interest, the 2016 meeting, held in Lima, Peru as this book

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was being written, featured specialists and students from 23 different countries. The last point is publication. The Museum of Man in San Diego publishes a Bibliography of Human Paleopathology and Related Subjects, available as a hard copy or on disk. Two new books are The Handbook of Archeological Sciences, edited by Brothwell and Pollard, which contains a number of chapters relating to paleopathology and A Companion to Paleopathology, edited by A. L. Grauer, both containing chapters on mummies written by myself. Another is The Global History of Paleopathology, edited by Jane Buikstra. As interest in the field increases, the number of journals accepting paleopathology articles also increases. Science, the Bulletin of the New York Academy of Medicine, the American Journal of Physical Anthropology, and the International Journal of Paleopathology publish many articles in the field. The Paleopathology Newsletter is now a vehicle for information on current events and publications in the field. The classic literature and more recent articles and books of greatest importance are readily available via the internet.

Chapter 3

AN ALEUT MUMMY COMES TO WASHINGTON In the late 19th and early 20th centuries, mummies were found in burial caves that had been discovered in the mid-Aleutian Islands. In 1874 a large group of mummies was removed by Captain E. Hennig of the Alaska Commercial Co and donated to the Smithsonian Institution; one was later transferred to the Peabody Museum at Harvard University. Unfortunately, almost all of the Smithsonian mummies collected by Captain Hennig were skeletonized by the museum in the 1920s. Dr. Aleš Hrdlička, Curator of the Division of Physical Anthropology at the Smithsonian Institution in the early 20th century, one of the first scientists to believe that America was populated by migration from Asia across the Bering Strait, led ten expeditions to Alaska, Kodiak Island and the Commander and Aleutian Islands. In 1938 he collected a number of mummified Aleuts from a volcanically heated cave on Kagamil Island, in the central part of the Aleutian chain. Only two of these Kagamil mummies have been examined, the middle aged male from the Smithsonian Institution who became the object of Lt. Yeatman’s interest and the mummy from the Peabody Museum, a middle aged female who eventually was studied by the Paleopathology Association (HUM-II, see Chapter 11).

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The mummy Lieutenant Yeatman and I examined in 1969 was probably of the immediate pre-Russian era (prior to 1740 CE). There was insufficient archeological data for more precise dating, and the mummy was felt to be too recent for radiocarbon dating. The cold damp climate of the Aleutian Islands would appear to be ill suited to the practice of mummification, which is generally based on desiccation. Hrdlička attributed the development of mummification by the Aleuts to a reluctance to depart with the deceased, while Laughlin points to the anatomic interests of the Aleuts in conjunction with their desire to preserve and use the spiritual power residing in the human body. The Aleuts of that time were anatomically sophisticated, performing autopsies on humans and comparative studies on sea otters. The Aleuts studied comparative anatomy, using the sea otter as the animal most like man. They conducted autopsies on their dead and had an extensive anatomic vocabulary. Mummification as an Aleut funerary practice is seen as an extension of their pragmatically oriented society. The technique of mummification varied with the social status of the deceased. The bodies of tribal leaders and hunters were eviscerated through an incision in the pelvis or over the stomach. No chemicals were used but fatty tissues were removed from the abdominal cavity, which was stuffed with dry grass. The body would then be put in running water, which completed the removal of fat, leaving only skin and muscle. The body was then bound with the hips, elbows and knees flexed. This position has variously been explained as an imitation of the fetal position, an attempt to economize on space, or an effort to prevent the dead from returning and harming the living. Another more likely possibility is that the flexed position is the habitual leisure position of the Aleuts. The binding of the mummy bundle is considered to be an effort to maintain the deceased in a comfortable position. Mummification was achieved by drying the body in the air or carefully over a fire, with repeated wiping of extruded moisture. When drying was complete, the cords were removed and the mummy wrapped in the deceased’s best clothes, usually a coat of aquatic bird skins. The mummy could then be encased in a waterproof coat of sea lion intestines followed

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by various layers of seal, sea lion or otter skins and perhaps some matting. The entire bundle would be tied with braided sinew cord and removed to a burial cave, where the mummies were placed on platforms or suspended from the ceiling to avoid contact with the damp ground. The cave in which this mummy was found was heated by a volcanic vent, creating a preservative warm dry atmosphere. These caves were probably used only for a few hundred years before the Russian contact of the early 18th century. An Aleut tale, explaining the use of the warm cave, tells of a rich headman, Little Wren, who lived near the cave on Kagamil Island. His young son was accidentally killed by his brother-in-law in a boating accident. In the subsequent funeral procession, the boy’s pregnant sister slipped on a rock and suffered a fatal miscarriage. As the season was snowy and cold, the chief decided to place the bodies in the nearby cave, which had previously been used for storage. The chief declared that the cave would become a mausoleum for his entire family and when he died of grief shortly afterward, he was interred there with all his possessions. It is thought that the body of Little Wren was removed from the warm cave in 1874 by Captain Hennig. Dr. Hrdlička removed some 50 mummies from the cave in 1938. Other than blood group determinations, the mummies remained undisturbed at the Smithsonian until Lieutenant Yeatman and I performed our study in 1969. It was fortunate that the mummy selected was apparently that of a common man, as it had not been eviscerated. X-rays of the 112 cm (3’8”) long coffin shaped fur wrapped mummy bundle revealed a body flexed at the hips and knees, with the arms extended down between the legs. Pathology included minimal arthritic changes in the back, periodontal disease and dental attrition. Encouraging was the evidence of the outlines of the heart and lungs, suggesting that this was the body of a common man. Radio-opaque masses were seen in the lower abdomen. The wrappings were removed sequentially. The outer 5 were animal skins, probably sea otter. The innermost layer was an eiderdown parka,

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composed of numerous bird skins sewn together with the feathers on the inside and a spotted fur collar. The body was that of an adult male of indeterminate age in the flexed position seen on the X-rays. The weight was approximately 10 kg (22 pounds) and the overall length of the body was 165 cm (64 inches). The skin was dark brown, dry and leather-like. The face was partially covered by a bird skin, probably a cap that had slipped down. He was partially bald and the hair appeared singed, suggesting that the body had been suspended over a fire for desiccation. A mustache and full beard were present. Other than the shrinkage of mummification the neck, chest, abdomen and genitalia were unremarkable. No skin incisions were seen. Another bird skin, a pouch with several leather thongs at one end, was lodged between the left arm and the left side of the abdomen. We were disappointed to find that it was empty. There was a full complement of teeth, in normal occlusion. Extreme dental attrition was present, with heavy dental calculus and periodontal bone loss. How does one do a first mummy autopsy? The skin was extremely hard, so the usual scalpel approach was not going to work. The option was a Stryker autopsy saw, ordinarily used to open the skull to remove the brain. This remarkable instrument, similar to those used for removing casts, has a small reciprocating blade; it can cut hard material but will not cut skin. A rectangular window was cut into the chest and abdomen and the heart and lungs were identified. The heart was markedly flattened, measuring 9 cm wide, 8 cm high and 1 to 2 cm thick. It was fixed posteriorly and inferiorly to the adjacent tissue and was recognizable as the heart by its position, general shape and relation to the aorta. The chambers could not be identified. The organ was opened by several transverse incisions. The usual cardiac structure was completely obliterated and replaced by multiple layers of unidentifiable tissue. Several superficial 1 mm white dots were seen on one of the inner layers. The lungs were extremely brittle and were removed in several fragments roughly corresponding to the lobes. The cut surfaces of the lungs had a sponge like appearance suggestive of preserved pulmonary architecture, except for the right lower lobe, which was putty-like and

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homogeneous. The lungs were partially adherent to the diaphragm and chest wall, a finding consistent with a previous bout of pneumonia and something that we have since found in the bodies of almost all the ancient inhabitants of this harsh climate. In order to expose the abdomen, the lower extremities were disarticulated at the hips and the left forearm at the elbow. The ventral abdominal wall was then removed. The abdominal viscera were poorly preserved; in fact, the stomach, small intestine, liver, spleen, pancreas, adrenals, urinary bladder, and prostate could not be recognized. The kidneys were represented by ill-defined retroperitoneal masses. Only the left half of the transverse colon and the descending colon were identifiable. They were filled with numerous dark brown, faceted, hard fecal masses. These coprolites corresponded to the abdominal radio-opacities seen before the abdomen was opened; they presented the same appearance when xrayed after removal from the colon. They averaged 2.5 cm. in diameter, and presented a homogeneous dark brown appearance on section. The remaining abdominal tissues were removed. The rectum was slightly dilated; it measured 7 cm. in diameter and was filled with fecal material. The abdominal aorta and iliac vessels were well preserved and easily identified. A firm yellow plaque measuring 2 by 1 cm was noted in the right iliac artery but there was no other gross evidence of atherosclerosis. The skull was intact and examined after removal of the top, the calvarium. The membranes covering the brain, the dura, were found to be intact, thin and transparent in the frontal area and thicker and opaque elsewhere. Upon removal of the dura the brain tissue was found to be shrunken into the posterior fossa of the cranial cavity, the major portion of which was empty. The roughly rectangular brain measured 14 by 10 by 5 centimeters and was covered with a fine crystalline material. No external features were identifiable, and the cut surface presented a homogeneous brown appearance throughout. The various tissues were sampled, rehydrated with Ruffer’s solution and examined microscopically. The heart contained numerous small foci of crystalline material, which were subsequently diagnosed as bacterial

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abscesses. The lungs showed several pathologic changes. The right lower lobe was reduced to an amorphous mass. The other lobes were well preserved but abscesses similar to those seen in the heart were present in the other lobes and the trachea. A moderate amount of black anthracotic pigment was noted throughout. Atherosclerosis was present in the aorta and other arteries. Examination of the teeth revealed severe wear, with repair processes. The reduction of the lower lobe of the right lung to a consolidated mass was the most remarkable gross pathologic change in the mummy. Histologic examination confirmed the destruction of the tissue in this area and revealed the presence of free gram-negative bacilli. Multiple small aggregates of crystalline material, often containing the same gram-negative bacilli, were found, not only in the right lower lobe, but in the other lobes of both lungs, the heart, trachea (within sinus tracts), and retroperitoneum. There were a number of possible explanations for the appearance of the right lower lobe and the crystalline areas. A component of postmortem change is indisputable; the question was one of degree. Did these areas represent ante-mortem disease or were they due entirely to postmortem change? The posterior midline position of the remains of the brain indicated that the body was in the supine position during the postmortem period of liquefaction of the brain and subsequent desiccation. While the condition of the lower lobe of the right lung could have been a manifestation of postmortem autolysis, one would have expected, given the supine position of the body, that a change of this nature would have involved the posterior portions of both lungs. The mummification of the other lobes was evidence against autolysis. Conversely, the failure of one lobe to mummify implied a predisposing factor, such as ante-mortem disease. Analysis of the crystalline material revealed it to be inorganic and not to be confused with adipocere, a wax-like material formed by the postmortem action of bacteria on body fat, consisting primarily of palmitic, stearic, and hydroxystearic acids. No adipocere was seen grossly, although the foggy and hazy conditions common in the Aleutians are said to favor the formation of adipocere. The crystals of adipocere are found only in

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tissues containing fat and not in such structures as the lung and trachea. It was thus apparent that the crystalline material was not adipocere but probably represented postmortem mineralization of areas containing discrete aggregates of gram-negative bacilli. There were two possible explanations for the presence of the bacteria in the crystalline foci. One was that the bacilli were present throughout the tissues and were preserved only in the areas of mineralization. Many gramnegative and gram-positive cocci were scattered throughout the tissues and it was difficult to imagine a process that would have preserved bacilli selectively in one area and cocci in another. The more plausible explanation was that the crystalline foci represented ante-mortem bacterial abscesses. The preservation of bacteria for 300 years is not unusual; bacteria have been stained in the intestinal contents of a 4,000-year-old Egyptian mummy. The bacteria may have had a role in the process of mineralization by invoking a mechanism similar to that which results in adipocere. Proteolytic bacterial enzymes may produce a localized acidic environment conducive to the deposition of calcium salts, especially if supersaturation resulted from desiccation. The distribution of the crystalline areas also suggested ante-mortem abscesses. As the bacteria in these foci appeared to be the same as the gram-negative bacilli in the right lower lobe, one could infer that the terminal illness was lobar pneumonia (possibly caused by Klebsiella pneumoniae), with septicemia and multiple visceral abscesses. Attempts to identify the organisms immunologically were thwarted by the non-viability of the bacteria. Postmortem changes had altered the picture considerably. While they might have caused all the changes described, this appears improbable for the reasons already given. The lack of preservation of the abdominal viscera made it impossible to evaluate the role of intra-abdominal pathology in the death of this individual. The involvement of the tracheal cartilage was explained by postmortem loss of the resistance of the mucosa to infection. Bacteria present on the mucosal surface at the time of death may have invaded the mucosa and underlying cartilage, thereby producing the sinus tracts seen.

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The pulmonary anthracosis can be attributed to the culinary habits of the Aleuts. Until recently they prepared their food over an open seal-oil fire, which filled their homes with smoke. Indeed, ocular changes in the Aleuts, noted by early visitors, were attributed to the smoke and modern visitors have found it impossible to live in ancient Aleut houses for the same reason. The lungs showed changes consistent with moderate emphysema and bronchiectasis, probably of the same origin. Tobacco may be ruled out as a cause, since the use of tobacco was unknown before the advent of the Russians. Severe masticatory dental stresses was indicated by marked dental attrition, increased thickness of the lamina dura, prominent hypercementosis of the tooth roots, and significant deposits of tertiary dentin. The presence of periodontal disease was manifested by deposits of heavy dental calculus, periodontoclastic bone changes, and migratory protrusion of the anterior teeth. There was no evidence of impacted or supernumerary teeth, missing teeth, dental caries, or malocclusion disorders. Similarly, the maxillary bone and antrum exhibited no pathologic changes. A possible atheromatous plaque was noted in the inferior labial artery. Sections of the major blood vessels showed only mild focal atherosclerosis of the iliac vessels. This finding, combined with the X-ray evidence of mild arthritic changes, enabled us to estimate the age of the subject at the fourth or fifth decade. There were two interesting incidental findings. Chondrocytes (cartilage cells) appeared to be well preserved, even at the ultrastructural level. An inexplicable finding was the presence of several hair shafts in single follicles, a feature of animal fur, in a section of skin, possibly due to adherent animal skin as an example of psuedopathology. The negative findings were also noteworthy. There was no evidence of trauma and no foreign material or organisms were seen in the pulmonary alveoli, ruling out accidental death by drowning. No poisons were found in the tissues analyzed by neutron activation. Stains for fungi and tubercle bacilli were negative. No parasites or parasitic ova were seen in the coprolites.

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The blood group, determined on bone from the femoral head, was type O. Blood groups have been successfully determined in varied mummified material. 30 of the Aleutian mummies were typed when they arrived in Washington, D.C., by use of vertebral bone corings. The blood-group distribution was: eleven O, eleven A, six B, and two AB. These results are in contrast to the prevalence of type O in Eskimos and American Indians (although some type A is found among Northwest Coast Indians). The Aleuts have an almost identical blood type distribution to that of Eastern Siberian tribes, but the number of individuals typed may be too small to draw any valid conclusions regarding the origin of the Aleuts. In summary, examination of a 200 to 300-year-old Aleutian cadaver mummified by desiccation indicated that the cause of death was lobar pneumonia caused by a gram-negative bacillus, probably Klebsiella pneumoniae, complicated by septicemia and diffuse metastatic abscesses. The abdominal viscera were not preserved, and the role of intra-abdominal disease in the death of the subject could not be assessed. Other findings included pulmonary anthracosis and mild atherosclerosis. Severe masticatory dental stresses and periodontal disease was evident. There was no evidence of death from trauma, drowning, or poisoning. In the course of this mummy examination, I took my wife Barbara and three year old daughter Jill to see the object of my excitement. As we neared the door of the laboratory, Barbara said, “What’s that smell?” Her pathologist husband, accustomed to the odors of a wide variety of bodies, responded, “What smell?” Mummies basically smell like old leather bound books. Jill’s eyes widened at this shriveled up, dark brown body but she didn’t say anything. Several weeks later she started asking questions about death and dying and Barbara launched an intensive training course in various religious concepts of death, dying, and the afterlife. This process went on for several weeks, until Jill finally said, “You mean, when you die, you don’t go to the Smithsonian?!”

Chapter 4

THE DOCTOR BECOMES A GRADUATE STUDENT Having entered the fascinating but largely dormant field of paleopathology, I took a course in Physical Anthropology at George Washington University from the now deceased Larry Angel, while continuing the research program at WRAIR. The high points of my military career became the mummy autopsy and the winning of the post basketball championship by my team, the Old Folks (a bunch of 30 yearold docs). In 1970 Richard Nixon became President and he decided that the Army didn’t need all these three year people, so I was discharged. As there were no positions open for pathologists at that time in the Washington area, we chose to move to Philadelphia, where I was fortunate to obtain a position at a community hospital. I applied and was accepted to graduate school in anthropology at the University of Pennsylvania and stayed at the community hospital for two years before moving on to an Assistant Professorship in the Pathology Department at the Hospital of the University of Pennsylvania. I was a physician in the mornings and several afternoons a week a lowly graduate student across the street at the University Museum. The Chairman of the Anthropology Department referred to me as Mr. Zimmerman until the day I was pleased to report to him that a biopsy of a lesion in his wife was benign, which changed my

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status to Dr. Zimmerman. When I am asked how I was able to combine graduate school with a full time hospital position, I point out that for seven years I never turned on a television set! As the Anthropology Department was kind enough to give me credit for several medical school courses I was able to complete my course requirements in five years, and needed only a thesis for my Ph.D. My lucky day came when one of my advisors told me that a Penn Museum team working in the Luxor, Egypt area was excavating tombs and had found a large number of mummies. All we had to do was the necessary paperwork, including visas and clearance from the Egyptian Antiquities authorities and assemble a mummy dissecting kit to take on a flight to Cairo. Security for flights was considerably less strict in 1974, as the 10 inch long dissecting knife in the kit was accepted as a surgical instrument, with the comment, “Oh, it looks very delicate.” Next we had to wend our way 400 miles south to Luxor, on a third hand Russian sleeper train. The modern city of Luxor, on the east bank of the Nile, 400 miles south of Cairo, is the site of ancient Thebes, one of the capitals of Egypt during the first half of the New Kingdom. The Nile Valley at this point is four to five miles wide, bounded east and west by limestone cliffs some 1,000 feet high. The ancient Egyptians, observing the sun setting on the west bank, concluded that it traced a nightly journey through the underworld to rise in the east. They buried their dead on the west bank, in order that the soul of the deceased might follow the same path and rise again every day. The Theban necropolis contains the Valley of the Kings, burial place of the New Kingdom Pharaohs. Set into the eastern face of the nearby hills and cliffs are the tombs of hundreds of lesser officials and priests from the New Kingdom through the Saite period (Dynasties XVIII- XXVI, c. 1580525 BCE). The Penn Museum expedition, funded by the Smithsonian Institution Foreign Currency Program and under the direction of Lanny Bell, at that time a doctoral candidate, was studying a group of tombs at a site known by the name of the overlying Arabic town of Dra Abu el-Naga (or simply Drabu Naga). This site, located on the road between the mortuary Temple

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of Queen Hatshepsut at Deir el-Bahari and the Valley of the Kings, was initially excavated from 1921 to 1923 by Clarence S. Fisher, then Curator of the Egyptian Section of the University Museum. Twenty-two decorated tombs of officials of Dynasties XIX-XX, ca. 1314-1085 BCE., were cleared, with the recovery of many burial goods. When Fisher ended his excavation in 1922 he had just reached the largest tomb, No. 157. Examination of an associated mud-brick pyramid was completed but he never returned to the tomb and issued only a preliminary report in 1924. In 1966 a continuing investigation of the site was organized by Dr. David O’Connor of the Egyptian Section of the Penn Museum, Mr. Bell, and Dr. Jaroslav Černý (since deceased) of Oxford University. The aim of the renewed project was to verify the records of the earlier expedition and to complete the excavation and clearing of the tombs. The concentration was on the decorated tombs, as major sources for the understanding of funeral and burial customs, religious beliefs, social structure, daily life, and architectural and artistic traditions. Restoration and translation of the hieroglyphs yielded much genealogical and historic information. Among the original occupants of the tombs were the three High Priests of the chief god of the Egyptian Empire, Amun of Karnak, during the reign of Ramses II (1304-1237 BCE.). The later Ramesside Period saw a marked growth in the power of the High Priest of Amun, and it was hoped to be able to illuminate the early stages of that change. The tombs of the three High Priests are Nos. 35 (Bekenkhons I), 157 (Nebwenenef), and 283 (Roma-Roy). Nebwenenef, the first of Ramesses’ High Priests, died about 1290 BCE. Excavation of these tombs clarified the places of these three within the succession of the High Priests of Amun during Dynasties XIX and XX. In this trip and a second one five years later, I examined mummies from the tombs of Nebwenenef and Bekenkhons. The tombs are similar in design, consisting of a mud-brick pyramid above and behind an enclosed fore-court cut into the cliff-face, a series of rock-cut chambers, and a tunnel descending several hundred feet to the actual burial chamber. The tombs contain the funerary stele, or gravestone, of the owner. Statues of the deceased and his wife were in one of the chambers. The walls and

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exposed chambers were all decorated with brightly painted hieroglyphic inscriptions, giving the name and title of the deceased and his family, and religious and funerary texts. The long burial shafts in these tombs were eventually filled with many intrusive burials. Unfortunately, the tombs suffered many indignities through time, including the intrusive burials during later Dynastic times that became my “patients”, human habitation, exploitation by antiquities hunters and plunderers, and occupation by bats. All of these have resulted in a markedly altered appearance. The first step undertaken by the archeologic team was finishing the uncompleted study begun by Fisher. A preliminary survey of the upper halls, tunnel, and lower rooms had been done but there was no excavation of the tomb of Nebwenenef. A survey by Bell in 1967 revealed it to be choked with the rubble of various periods, pitted and churned by robbers’ trenches. Near the entrance, the deposit reached a maximum height of some 2 meters. Stratigraphic excavation and statistical evaluation of this material allowed an historical reconstruction of the habitation and use of the tomb. The upper rooms of the tomb were not used for habitation until the Coptic period. No stratum of the dynastic period was seen and only a single shawabti (tomb figurine) fragment was found in this area. The Coptic occupation, probably c. 730-835 CE, was associated with the proliferation of monasteries over the Theban necropolis. The Coptic stratum consisted of a layer of black ash containing charred fragments of wood work, probably the remnants of the furniture of a Coptic monk. The evidence of conflagration suggested an abrupt and violent termination for this period. The tomb was unoccupied during the beginning of the succeeding Islamic period, as indicated by a layer of clean windblown sand. The tomb soon became subject to the depredation of tomb robbers. The stratum of this period consisted of thick black ash filled with small funerary amulets and the charred remains of mummies, probably burnt by the robbers for warmth or cooking fires.

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Sometime later in the Islamic period the tomb was reinhabited. A family lived in half of the broad hall of the tomb, stalling their animals in the other half. These inhabitants continued the pillage of the tomb, an occupation which has been practiced in Thebes since at least the XXth Dynasty. Not only mummies and their furnishings but even the decorations on the walls were looted. The occupation of the upper rooms probably ended shortly after 1876 AD, a Turkish coin of that date being found in the loose rubble on top of the occupation debris. The tunnel showed a similar stratification of the debris filling it, but with some important differences. The lowermost stratum was of Ptolemaic and perhaps Roman date. Many Pharaonic antiquities were found in this stratum, which was protected by a thick layer of Coptic refuse. Uninterested in pagan relics, the Copts presumably did not remove them. The fire noted in the upper rooms does not seem to have affected the tunnel. The uppermost, Islamic, stratum in the tunnel, reflecting a renewed interest in the sale of antiquities, contained many robbed and mutilated mummies. The presence of the still thriving Theban industry of manufacturing “antiques” was attested to by the finding of a large assortment of very poorly made and broken fakes. A secondary burial chamber was found to have been cut into the lower wall, and contained several fragmented mummies dated to the reign of Ptolemy III (246-221 BCE). Such secondary burials probably continued on into Roman times. Use of the tunnel and rooms of the tomb came to a definite end in 1913 with the installation by the Egyptian government of an iron door to protect the remaining inscriptions. All deceased Egyptians were mummified until the Christian era, ca 200-400 CE. There was always marked variability in the techniques of mummification and in the site of inhumation of the bodies, depending to a great extent on the economic and social status of the deceased. Although the mummies of the wealthy and powerful were placed in costly tombs, the poor had to make do with burial in the desert or in neglected tombs. The number of individuals buried in the tombs of Nebwenenef and Bekenkhons was estimated at a minimum of 50. It was apparent upon surveying the 7,358 specimens removed from the tombs that the grave

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robbers had done a thorough job; 5,919 of the specimens consisted of isolated finger bones and fragments too small to be identified. There were no whole mummies, with most of the large specimens consisting of heads and limbs, and a number of these were burnt. A disappointment was the absence of packages of organs (visceral packages). A large number of animal bones, teeth, and horns were also identified, as well as rare fragments of wood, some decorated, and a few potsherds. There were no complete mummies, although there were some major specimens, which provided some information on mummification procedures. The lower half of an adult male, after unwrapping, was found to be encased in resin, which remained in a semi-solid tarry state, indicating that the resin had been applied as a liquid, as is generally thought to be the case. One head still had the brain present and the ethmoid plate intact, while another had the plate fractured, with linen plugs in the nostrils, indicative of the variability of mummification practices. Several trunks were present, all of which had been eviscerated, leaving only the heart. There were 21 complete adult heads and 43 loose temporal bones (24 rights), comprising at least 45 adults. 5 immature mandibles were found, making a total count of 30. This estimate was in accordance with the counts of a number of the other bones, such as the 91 femoral heads, 15 sacra, 22 maxillary and 36 mandibular fragments in addition to the intact skulls, and 57 scapulae. These bones are most likely to stay intact, and are therefore the most useful in evaluating fragmentary collections. The anthropological analysis of this material was hampered by the fragmentary nature of the specimens. It was not possible to sex or age most of the specimens, almost all of which were adult. The sex ratio among the adults can be estimated either by the pelves or the skulls. 4 male and 5 female pelves were identified, while of the skulls sexed, about 2/3rds were considered male. The ratio derived from the pelves is probably more reliable, as sex determination of skulls is based on the size of the mastoid process and of the skull in general, both of which are obviously affected by the size of the individual. The pelvis is sexed by

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the angle of the sciatic notch, a feature unaffected by size. Unfortunately, most of the pelves were badly fragmented and only 9 could be sexed. At least two styles of mummification appear to have been used. One, based almost exclusively on desiccation, resulted in well preserved dried heads of a brown color, with no evidence of the use of resin. The other, probably of a later period, used large quantities of black resin that infiltrated the tissues and spread into the oral and cranial cavities and spinal canal. The mummy and skeletal material found in these tombs do not constitute a population in the usual anthropological sense but rather a somewhat random collection deposited in the tomb over a number of centuries, as suggested by the variation in mummification techniques. Restrictions by the Egyptian government on the removal of archeologic objects made it impossible to remove adequate samples of mummy wrappings for 14C dating. Therefore the dating of the specimens is archeologic, ca. 1,290 BCE-200 CE, and specific dates cannot be given for any individual specimens. A few of the specimens showed gross pathologic change, and a number of conditions were diagnosed microscopically, after rehydration in Ruffer’s solution. In view of the small number of individuals, a significant number of conditions were diagnosed. The specimen of most pathological interest was the relatively complete mummy of an approximately fiveyear-old child, consisting of the trunk and arms. The organs were found to be intact, although many maggots were present. The lungs were adherent to the chest wall, and there was a marked scoliosis (lateral curvature of the spine. The combination of these two changes suggested a diagnosis of tuberculosis and microscopic examination revealed tubercle bacilli in the vertebral bone. In addition there was fresh blood in the trachea and lungs and considerable iron pigment in the lungs indicating previous hemorrhage. The conclusion from these findings was that this child suffered from pulmonary tuberculosis with spread to the spine, with recurrent and finally fatal pulmonary hemorrhage. The child’s lungs also showed anthracosis.

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In other mummies, there was some evidence of infectious disease, including pleural adhesions of the lung to a posterior chest wall specimen. Two rib abscesses and a vertebral abscess were seen. These lesions consisted of small lytic areas with some evidence of surrounding osteoblastic reaction, a response seen in infectious rather than neoplastic processes. One case of probable mastoiditis was seen. There was one example, in a child, of cribra orbitalia, pitting of the roof of the orbit, a disorder that seems to be rare in Egyptian material, although it has been reported in remains from prehistoric Nubia. A section through the neck of one of the mummies showed severe atherosclerosis of a carotid artery, the major vessel supplying the brain. Atherosclerosis was also seen in iliac arteries from two complete pelves and in a radial and ulnar artery from a separate forearm specimen. Other diagnoses included Paget’s disease of the skull and bipareital thinning of the skull, an aging change. As in previous studies, evidence of neoplastic disease was minimal. There were only two benign tumors found in these mummies, a fibrous histiocytoma of the skin of the heel and a small osteoma of the skull. Another fragment of skull showed a small depression on the surface of the inner table, perhaps owing to the pressure of a meningioma. No lytic lesions consistent with metastatic disease were seen. There were three examples of spina bifida, an opening of the spinal canal. One healed infected fracture of the tibia and a well healed rib fracture were seen. Many vertebrae showed the lipping of degenerative joint disease. A mummified hand showed swelling of a finger joint, either due to trauma or possibly rheumatoid arthritis. Only a few carious teeth were found, but periodontal disease and loss of teeth was common. A number of the teeth were examined for lead levels, in an ongoing study of environmental pollution, showing values significantly below those in modern individuals. Examination of the eyes from three of the heads revealed preservation of some of the normal structures, such as the lens and the melanin pigment of the retina. No pathologic changes were identified.

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Material from one of the joints showed crystals suggestive of gout but this turned out to be resin, the distinction being made by the shape of the crystals and their failure to polarize light. The dismembered state of the mummies can be attributed to tomb robbers, whose activities were well documented in antiquity. A XXth Dynasty confession mentions a tomb within what latter became the University of Pennsylvania concession, No. 158, Tjanefer: “We...went to the tomb of Thanufer, who was third prophet of Amun. We opened it and we brought out his inner coffins, and we took his mummy, and left it there in a corner, in his tomb. We took his inner coffins to this boat, along with the rest to the Island of Amenope. We set fire to them in the night. And we made away with the gold which we found on them, and 4 kite of gold fell to the lot of each man ....”

The finding that a number of heads remained wrapped indicates that the tomb robbers knew, as was verified, that no jewelry was placed on the heads. This finding supports the probability that the robbers operated very shortly after death and mummification. The hands were particularly dismembered, in the search for rings. The organ packages of the adult mummies had probably been destroyed by robbers looking for included jewelry or scarabs. Two cautions by Calvin Wells should be kept in mind when evaluating material of this nature. One is that the best diagnoses in paleopathology are tentative at best and that is certainly true for a number of the diagnoses offered here (although the finding of tubercle bacilli must be considered absolutely diagnostic). Wells’ other point is that paleopathology must be more than a catalog of ancient miseries. The archeological relevance of these various pathologic disorders must be considered. The finding of tubercle bacilli in the child’s mummy firmly established the presence of tuberculosis in dynastic Egypt. Previous reports of tuberculosis have shown the classic lesions of the disease, but this is the first demonstration of the causative organism, Mycobacterium tuberculosis, in an Egyptian mummy.

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The inferences on social conditions and habitation patterns derived from this diagnosis are of special value in view of the almost exclusively monumental emphasis in Egyptian archeology. Only four town sites have been studied. The presence of tuberculosis in ancient Egypt verifies the impression that most ancient Egyptians lived in crowded living conditions, the disease being much more readily transmitted in crowded communities. Childhood tuberculosis is acquired by exposure to an individual whose sputum contains many infective organisms. Persons with recently acquired disease, i.e., children and young adults of the parental age group, are relatively noninfectious, in contrast to elderly persons (such as grandparents) with reactivated disease. The finding of childhood tuberculosis is thus indirect evidence suggestive of multigenerational rather than bigenerational households in ancient Egypt; this pattern persists today. This unfortunate child died of progressive primary tuberculosis. The finding of anthracosis in this young child confirms the presence of an open fire in the dwelling place. In the hot climate of Thebes, this was probably an oven fire for baking bread rather than a heating fire. The documentation of this condition in many areas has made it apparent that air pollution, once thought to be limited to modern, industrialized societies, has been a feature of human settlements for millennia. One small segment of an adult thoracic vertebra showed a bony ankylosis. The histology was non-specific and ankylosing spondylitis is a diagnostic possibility. As the vertebral bodies were intact, tuberculosis can be ruled out. As in previous studies of mummies, no malignant tumors were found. The fibrous histiocytoma reported is a not uncommon benign skin tumor in modern populations, but has not been reported previously in mummies. The relatively good preservation of this tumor is consistent with the preservation of tumors I later noted in experimental mummification studies (Chapter 5). This finding strengthened my feeling that if tumors existed in antiquity the paleopathologist would be able to identify them. The failure to find tumors probably indicates that cancer was a rarity or non-existent in antiquity. The implication is that factors existing in the modern world only are involved in the causation of cancer.

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An interesting finding in two of the specimens was an excellent degree of preservation of the thyroid gland. Study of this organ is important in paleopathology in that, at least in modern populations, most cases of thyroid carcinoma occur in young or middle-aged individuals, often with a history of prior radiation exposure. The objection to the absence of cancer in mummies based on failure of individuals in antiquity to reach the “cancer age” does not apply in this case, and the absence of thyroid carcinoma in ancient remains would strengthen the view that this tumor is radiation induced. Obviously, a more extensive study of mummified thyroid specimens is indicated. In contrast, atherosclerosis is clearly of great antiquity. The defects of dealing with fragmented remains were evident in studying the Drabu Naga collection. Although the aorta and coronary arteries, the primary sites of this disease, were not present to be examined, our individuals showed evidence of this disease. Several other arterial samples, including one slide of a coronary artery, did show atherosclerosis and I was reasonably confident that the clefts seen in the vessels diagnosed as atherosclerotic were due to cholesterol deposits and not some artifact of mummification. Three of the sacra showed spina bifida, an opening of the spinal canal. The resultant exposure of the spinal cord often produces paralysis and difficulties in controlling elimination. The finding of these specimens in adults implies that the social organization of ancient Egypt was sufficiently advanced to deal with what may well have been life-long disabled persons. Even in contemporary times such individuals are often major medical and nursing problems. The finding of only two healed fractures indicated lives relatively free of trauma for these individuals. One of these accidents must have been severe as the accompanying infection indicates an open (compound) fracture. The presence of this infection is evidence that this individual did not benefit from the knowledge contained in the earlier medical papyri such as the surgically oriented Edwin Smith Papyrus, which had been lost by New Kingdom times. Histologic examination of the bone specimens was generally disappointing, in that the decalcification necessary for sectioning resulted

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in dissolution of the specimens. This problem occurs when the underlying structure is severely autolyzed, although shorter periods of decalcification might yield better results. In any event, we were unable to verify histologically the gross diagnoses of rib and vertebral abscesses and skull osteoma. Several of the specimens were prepared by embedding in plastic rather than paraffin, with greatly improved histology. This technique is too costly for routine use, but should be considered for specimens of potential value. A number of the adults in this collection suffered from degenerative joint disease of the lumbar spine, which can be attributed to the rigors of a pre-industrial agricultural economy. The example of Paget’s disease of the skull is of some interest. This pathologic thickening of bone occurs only in the elderly, and is not uncommonly associated with the development of malignant bone tumors, although such was not the case in this instance. However this finding does show us that some individuals were of sufficient longevity to reach the “cancer age.” Biparietal thinning of the skull has been reported in other Egyptian material and in modern patients and is also an aging change. Based on admittedly fragmentary evidence, it is suggested that this population was well nourished and exposed to little trauma. Morbidity and mortality were primarily due to infectious rather than neoplastic disease. It is known that several different mummification procedures were used in ancient Egypt. Examination of these specimens showed that simple air drying resulted in the best preservation of histologic detail although perhaps not in external appearance, the major concern of the ancient Egyptians. In an attempt to improve preservation and representation of the living individual, the use of resin or bitumen was introduced in the New Kingdom. Continuing use of this technique suggests that it was satisfactory to the ancient Egyptians but from the point of view of the paleopathologist this innovation was a failure. The skin of the resinated mummies showed a coagulation necrosis of the type seen in thermal burns. This finding and the presence of resin in the spinal canal, having run down after instillation in

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the cranial cavity by the embalmers, confirms artistic representations of the resin being applied in a hot liquid state. In conclusion, study of the remains from Drabu Naga provided us with definite proof of the presence of tuberculosis and more evidence suggestive of the rarity or absence of cancer in dynastic times. More importantly, these conditions and the other findings listed above were evaluated in the context of our knowledge of habitation patterns and living conditions. Hundreds of Egyptian mummies have now been examined either histologically or radiographically. While a sample of this size does not permit a definitive statement on disease incidence, it does encourage some speculative remarks. The majority of the previous paleopathologic reports have been of a descriptive nature and a feature of the revival of interest in the paleopathology of Egyptian mummies has been the integrative approach possible because of the participation of specialists from many fields in anthropology and medicine. The examination of the material from Dra Abu el-Naga, while an entity unto itself, is properly seen as part of this overall inquiry into health and disease as facets of life in ancient Egypt. The attractiveness of the Nile Valley for human habitation with the reliable annual inundation as a basis for agriculture is obvious. The hidden costs of this ecosystem were not so obvious to the ancient Egyptians and remained obscure until the development of modern parasitology in the early 20th century A.D. The agricultural techniques, involving prolonged immersions and the rudimentary sanitary practices of the early inhabitants of the Nile Valley, provided perfect avenues for parasitism. The schistosomes took advantage of this situation many millennia in the past, probably evolving to human parasites from schistosomes infecting the water fowl the Egyptians were so fond of hunting. In view of modern statistics and the finding of schistosome ova in four of the eleven Egyptian mummies specifically examined for this disease, one can speculate that schistosomiasis was a virtually universal infection in ancient Egypt. The same inadequate waste disposal technology insured the transmission of many other parasites. For example, it is not surprising that a member of the upper class suffered from ascariasis (PUM-II, Chapter 6). Although he probably had an indoor toilet, the actual disposal of the waste

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was rather casual, and probably performed by the same servants who prepared or served his food, insuring continuity of the parasite’s life-cycle. The picture emerges of a society whose members, of all classes, lived in close proximity, in multigenerational households and shared exposure to the same pathogens. Although there is virtually no evidence of the malignant tumors that plague the 20th century, the living conditions of ancient Egypt insured transmission of infectious diseases, the presence of which has been verified by many studies. The chronic anemia of schistosomiasis and the other parasitic diseases, compounded by the debilitating effects of undernutrition, tuberculosis and other acute and chronic infections must have resulted in a population with a marginal health status (although still capable of astounding architectural and military exploits). This background of disease and undernutrition may have been a factor in the association of episodic political and administrative difficulties and agricultural failures with foreign military setbacks in the New Kingdom and Third Intermediate Periods. It is a tribute to the overall efficiency of the administrators of ancient Egypt (and perhaps indicative of even worse conditions elsewhere) that she was able to play the role she did on the stage of the ancient world.

Chapter 5

EXPERIMENTAL MUMMIFICATION Many paleopathologic studies in the past have concentrated on the examination of skeletal material, the limitations of which are well recognized. Most diseases, particularly the acute infectious processes, produce no detectable changes in the bones. Mummification, either spontaneous or artificially induced, has given us the soft tissue material from which one can gain further insight into the diseases afflicting earlier populations. This chapter covers an experimental approach to the histopathological examination of mummified tissue. Normal and pathologic issues obtained at postmortem examination were desiccated, rehydrated, and sectioned. The normal tissues provided a provided a baseline of the changes incurred by tissues during the process of desiccation and rehydration, while a follow up study examined the variations in preservation of pathologic disorders. At the time of this study I was Director of the Autopsy Service at the Hospital of the University of Pennsylvania. The tissues studied were obtained from adult human cadavers undergoing postmortem examination, which includes permission for further scientific study. All tissues were procured within 24 hours after death. The initial study involved small specimens taken from grossly normal areas of the heart, aorta, lung, trachea, liver, spleen, kidney, testis, skin, tongue, skeletal muscle, vertebral bone, and brain.

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Following were a variety of pathologic specimens selected as representative of several broad classifications of diseases including inflammatory and degenerative disorders, disturbances of circulation and tumors. Each specimen was bisected. One half was processed normally, being placed immediately in 10% formalin, and after a 24 hour period of fixation embedded in paraffin for sectioning. The other half was placed in an Elconap oven at 40°C (104°F) for seven to fourteen days, with the intention of simulating either natural or anthropogenic mummification. After this period the specimens were dry, dark brown, and reduced to approximately 10% of their original weight. The specimens were rehydrated with Ruffer’s solution, then fixed in absolute alcohol and embedded in paraffin. The paraffin blocks were sectioned on a Spencer Rotary Microtome. The sections were stained according to the techniques given in the Armed Forces Institute of Pathology Manual of Histologic Methods. Stains included the standard hematoxylin and eosin, which stains the nuclei blue and cytoplasm pink, the Masson trichrome (nuclei black, muscle bright red, cytoplasm red, and collagen blue), and the Verhoeff elastic stain (elastic tissue black). W.E. Evans investigated the histologic appearance of spontaneously preserved bodies and found that much information could be derived from bodies inhumed for many decades. He stressed the value of additional stains, particularly for connective tissue, beyond the standard hematoxylin and eosin. His study concentrated on the appearance of disease free tissues, and pointed out the problems involved in merely identifying the various organs. His conclusion was that the diagnosis of pathologic processes would be on another level of difficulty. Before investigating the change in appearance of pathologic lesions after desiccation and rehydration, one should be aware of changes induced in normal tissues by these processes. Oven drying produces changes similar to those seen in the tissues of natural human mummies. The tissue examined in this study permits the making of a number of general and specific comments. General architecture was quite well preserved in the viscera.

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Examination of the myocardium revealed preservation of the normal fascicular architectural pattern. The nuclei were reduced to smudged basophilic structures, although their central position was still discernible. Cytoplasmic cross striations were only faintly visible on the hematoxylin and eosin stained sections but were more easily seen with the Masson trichrome stain. The myocardium exhibited a metachromatic reaction to this stain after rehydration, many of the fibers appearing purple rather than red. The aorta was well preserved, with clear distinction possible between intima, media and adventitia. The Verhoeff elastic tissue stain was useful in demonstrating the preservation of the elastic tissue of the aorta. A.T. Sandison found this stain to be superior to several others in staining of artificially desiccated human arterial tissue. The alveolar architecture of the lung was preserved, although some areas appeared collapsed, and there was little cellular detail. Both bronchial epithelium and cartilage were preserved. The vessels were congested, and the outlines of red blood cells could still be seen. The tracheal mucosa was lost but the cartilage remained intact. Chondrocytes appeared well preserved within their lacunae and one could differentiate between nucleus and cytoplasm. The cytoplasm of the solid viscera, the liver, spleen, and kidneys, was poorly preserved, with loss of cell outlines and the development of a homogeneous eosinophilic appearance. The liver showed compression of the intervening parenchyma, with extensive destruction by gas forming bacteria, as might be expected from the organ’s vascular relationship to the gastrointestinal tract. Colonic bacteria have ready access to the liver after death, resulting in rapid putrefaction. The portal areas could be identified with a Masson stain by their relatively greater amount of fibrous tissue, although blood vessels and bile ducts could not be distinguished. Mummification did preserve fatty change of the liver, an effect of exogenous toxins (most commonly ethyl alcohol). Continued exposure results in cirrhosis, a fibrotic disruption of the normal architecture of the liver, with disruption of the vital and delicate relationship between the biliary and circulatory systems of the liver. A mummified cirrhotic liver showed

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preservation of characteristic division into pseudolobules by fibrous bands and areas of bile duct reduplication. The spleen suffered a similar fate, with destruction of the parenchyma and preservation of the fibrous trabeculae. Differentiation between the red and white pulp remained possible. Examination of the kidney revealed severe autolysis, particularly of the tubules. The glomeruli were recognizable by their larger size and denser cellularity as compared to the tubules. Many of the glomeruli were poorly delineated from the surrounding tissue. The status of Bowman’s capsule and the small blood vessels could not be evaluated. The testis showed a marked change, the tubules appearing collapsed, simulating an epithelial pattern. Spermatozoa could not be identified. Skeletal muscle fibers were slightly swollen by the desiccationrehydration procedure, and showed retention of cross striations, both in the subcutaneous muscle and that of the tongue, especially evident with the Masson trichrome stain. The squamous epithelium of both skin and tongue was well preserved. Small subepithelial nerves were seen in both sites, as were well preserved pilar units in the skin (hair follicles with associated sebaceous glands). The basal layer was discernible, and, while there was general blurring of the cell borders, in areas intercellular bridges remained apparent. Nuclei generally remained intact, although intranuclear detail was lost. Sections of vertebral bone showed preservation of the cortical and medullary bone. Osteocytes appeared well preserved, apparently entrapped within their lacunae, as were the chondrocytes in the tracheal cartilage. The marrow was completely autolyzed, only a small amount of adipose tissue remaining visible. While Brothwell suggested that such preservation is artefactual, the demonstration of ultrastructural detail in the material within the lacunae indicates a protective function for cartilage and bone, with improved preservation of cells. The substance of the brain acquired a deep eosinophilia. Intracellular detail was lost but neurons could be differentiated from glial cells by the preservation of the neuronal cytoplasm.

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Histological sections of the tissues used in this study revealed changes in the tissues generally resembling those seen in human mummies. The degree of preservation with a one to two week period of dehydration of small fragments of tissue was surprisingly good. The continuing study of pathologic lesions resulted in my publication, with anthropologist Marc Kelley, of the Atlas of Human Paleopathology, as a baseline for more extensive paleopathologic investigations. The experimental approach produces changes similar to those observed by myself and others in the tissues of actual human mummies, although mummies are not quite as well preserved, especially the nuclei of cells, probably as a result of slower or more erratic desiccation and more severe bacterial and fungal contamination. Although a significant degree of variability was observed in the preservation of pathologic lesions, the results of the study can be extrapolated to actual mummies. While it was almost always possible to make the correct diagnosis, specific difficulties were noted with different classes of disease. Among the inflammatory disorders, non-specific processes showed poor preservation. Inflammatory cells were generally not as well preserved by mummification as causative infectious organisms. In particular, neutrophils, the cells of acute inflammation, are in essence containers of proteolytic enzymes and after death they lose their self-protective mechanisms and autolyze very quickly, assuming an irregular basophilic granular appearance, if they remain to be seen at all. Similar structures have been interpreted as autolyzed neutrophils in Egyptian mummies and my study confirmed these authors’ impressions. The growth of bacteria and particularly fungi was arrested by desiccation, even in areas of destruction of the surrounding tissue. The cells of chronic inflammation, lymphocytes, plasma cells and histiocytes, do not have the same self-destructive tendencies and are thus better preserved. The first two appear as indistinguishable round cells, while the larger histiocytes remain better preserved, allowing a less equivocal diagnosis of chronic inflammation. However, an example of chronic osteomyelitis was indistinguishable from carcinoma metastatic to bone.

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Pulmonary inflammation was generally well preserved, as the aeration of the lung allows rapid desiccation, limiting the autolysis seen in the solid organs. Bacterial stains revealed marked postmortem multiplication but fungi tended to remain much more localized after mummification. The accumulation of anthracotic pigment in the lymphatics of the lung is a process seen in almost all humans due to exposure to smoke from various sources. This black pigment is still easily seen after mummification. Pulmonary fibrosis is at the expense of elastic tissue and the usual Verhoeff stain for elastic tissue stains it black, producing confusion with anthracotic pigment. Elastin is purple with the aldehyde-fuchsin stain, avoiding this confusion. Collapse of the lung, atalectasis (associated with bed rest or penetrating chest injury) was not diagnosable in the mummified tissue, the lung presenting a uniform and unremarkable appearance. In a later study, atelectasis was identified in two crushed Eskimo mummies (Chapter 13). Wide dissemination of fungi in the tissues of a mummy probably indicates postmortem contamination and/or inadequate mummification or conservation, as was seen the mummy of Ramses II, which was flown to Paris in 1976 for radiation treatment of widespread fungal contamination. Tubercle bacilli rarely have been identified in ancient material and an attempt specifically to replicate this finding experimentally was not attempted, due to the health hazard of drying tissue containing living tubercle bacilli. Sarcoidosis, a granulomatous disease that shows a similar pathologic picture but without infectious organisms, was examined instead. The diagnosis of granulomatous disease was easily made. On the other hand, osteomyelitis was indistinguishable from metastatic undifferentiated carcinoma. The diagnosis of osteomyelitis can be difficult in fresh tissue and the carryover of this difficultly into the realm of mummified tissue must be accepted. Degenerative processes were quite well preserved in mummified tissue, often appearing little different from the fresh tissue. These conditions are generally characterized by the accumulation of various tissues and foreign materials, such as fat, cholesterol, pigments and fibrous tissue, all of which tend to be remarkably inert and persistent. Fibrous and

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elastic tissue are well known to be better preserved in mummies than epithelial tissues, although it is actually the intracellular collagen and elastin that persists, the cells themselves degenerating. A cirrhotic liver and fibrotic lung remained diagnosable. A mummified fatty liver was in fact better preserved than normal liver and it may be that the fat acted as adipocere on a microscopic level. Adipocere is a soap-like decomposition product of fat that has an antibacterial preservative effect on the surrounding tissues at the gross level. The spread of the gas forming bacteria that usually destroy the structure of the liver was markedly inhibited in this case. A persistent pigment was found to be lipofuscin, a degenerative brown pigment found in the heart and liver. George Smith and I reported this pigment, associated with aging and atrophy of involved organs, in the liver of an older adult Alaskan mummy (Chapter 12). Paget’s disease of bone presents a very characteristic mosaic microscopic pattern. The mummified tissue showed the thickened bone spicules but the mosaic pattern, although still discernable, was not as evident as in the fresh tissue. The ability to diagnose Paget’s disease of bone is of importance. In modern populations Paget’s disease affects up to 30% of those over 40 and accounts for a second peak in incidence of osteosarcoma in the aged, the first peak being in the second and third decades of life. Nearly 60% of bone sarcomas arising in those over 40 years of age are associated with Paget’s disease. Osteosarcoma is exceedingly rare in ancient material and the finding of Paget’s disease would indicate an individual at least more susceptible to malignancy. The great rarity of osteosarcoma in antiquity raises questions about its cause, which is unknown but appears to be related to factors present only in modern societies. Conditions of disturbances of circulation were variably preserved. The deposition of fat and cholesterol in the walls of arteries in atherosclerosis is well preserved by mummification. The characteristic cholesterol clefts became ovoid but were easily identified, as was calcification. Arteriosclerosis of small vessels was not recognized but atherosclerosis of large vessels was easily identified, due to deposition of fat, cholesterol and calcium. These arteries, with their roughened walls and compromised lumina, are liable to occlusion by thrombosis. A mummified

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thrombosed coronary artery showed preservation of calcific atherosclerosis but the thrombus was reduced to eosinophilic material indistinguishable with H&E from a mummified postmortem blood clot. Blood clotting is a postmortem or extravascular phenomenon and differs both grossly and microscopically from antemortem thrombosis, which consists of red and white blood cells suspended in a meshwork of fibrin and platelets. The phosphotungstic acid hematoxylin (PTAH) stain, which showed very well the exquisite fibrin meshwork of the thrombus in the control slide, stained the material in the lumen of the mummified vessel a diffuse blue. The red cells and the fine detail of the fibrin were no longer seen but the mesh-like pattern remained. Diagnosis of a mummified dissecting aneurysm of the aorta was facilitated by the use of specific stains. An elastic tissue stain differentiated between the dissecting blood clot and the highly elastic aortic wall. PTAH stained the fibrin and erythrocytes of the clot a deep blue in contrast to the red of the aortic media. Disease of smaller vessels, such as renal arteriosclerosis (often associated clinically with hypertension) was not recognizable after mummification, even though glomeruli remained fairly well preserved. Areas of hemorrhage were also poorly preserved. Coronary thrombosis is associated with acute myocardial infarction (AMI, “heart attack”), death of large areas of the heart muscle. Disappointing but understandable was an inability to diagnose an acute myocardial infarction. The mummified necrotic muscle could not be distinguished from the adjacent autolyzed myocardium and only a suggestion of the acute inflammatory reaction remained. In contrast, the fibrosis of a healed MI showed up very well, particularly with the trichrome stain. Lipofuscin, a degenerative pigment seen in the organs of the aged, was well preserved in both the healed infarct and the adjacent myocardium. The process of necrosis in an infarct is essentially identical to autolysis. The blood flow in both cases ceases and the muscle dies. In an infarct there is a peripheral acute inflammatory reaction, which is poorly preserved by mummification. As some six hours pass after the injury before the inflammatory reaction, it will not be seen in mummies in cases

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of immediate death (as is true in modern cases as well). It must be conceded that the diagnosis of sudden death due to AMI, with its implications for diet, life style, and the other factors that have been suggested in this disease, cannot be made in mummified tissue. The diagnosis of a healed MI, on the other hand, is more easily made as large areas of fibrosis are readily seen. An interesting point was the preservation of the cardiac muscle adjacent to the healed infarct. The nuclei were easily seen, due to the hypertrophy that occurs in regenerative myocardium adjacent to an old infarct, the nuclei becoming large and dark staining (hyperchromatic). Although shrinkage does occur with mummification, these cells are still better seen than normal cells. This phenomenon has implications for tumor cells, as noted below. Chronic heart failure due to fibrosis leads to chronic passive congestion and edema of various organs. Red cells break down, with accumulation of the breakdown product of hemoglobin, hemosiderin, an iron containing brown pigment, in the tissues. A stain for iron was useful in demonstrating the deposition of hemosiderin in the lungs and spleen. Another occlusive intravascular phenomenon is embolization, obstruction of blood vessels by masses carried in the blood stream. The example studied was an easily recognized bone marrow embolization to the lung, secondary to a traumatic bone fracture at the time of death. The characteristic admixture of hematopoietic cells and adipose tissue was clearly seen in small vessels in the lung after mummification. This finding could serve as a marker for a traumatic death. Both primary and secondary (metastatic) malignant tumors were included in this study. Two variants of carcinoma of the lung remained recognizable as masses replacing most of the lung. Well preserved was the malignant nature of the tumor cell nuclei, with variation in size and shape (pleomorphism) and dark staining (hyperchromatism). Breast cancer is characterized by infiltration of the breast by rows and sheets of malignant cells, occasionally forming a poorly differentiated glandular pattern. The mummified tumor lost this glandular pattern but was still diagnosable as infiltrating sheets of malignant cells.

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There was some variability in the preservation of other tumors. Intestinal tumors were autolyzed and unrecognizable. Cancer of the prostate and leukemic infiltrates could still be recognized. Metastatic tumors are of particular interest in that the microscopic pattern is on occasion sufficiently distinctive that the site of origin can be suggested with a good degree of confidence. For example, papillary carcinoma, which originates most commonly in the ovary or thyroid gland, tends to form whorled calcific structures called psammoma bodies. These structures are well preserved by mummification. Adenocarcinomas (glandular cancers) generally arise in the gastrointestinal tract. Metastatic carcinoma from the colon to the liver, lung and bone was examined. In each case, the mummified tissue showed preservation of the atypical glandular pattern. In the liver, the large pleomorphic and hyperchromatic nuclei were in marked contrast to the nuclei in the normal liver. In general, the tumors were better preserved than adjacent unaffected tissue. Examination of less distinctive metastatic tumors produced expected results, i.e., tumors were present but the tissue of origin (in these cases breast and lung) could not be determined. Malignant tumors in antiquity are conspicuous by their relative absence. This fact has usually been explained by the short life span of earlier populations, with death intervening before the “cancer age”. There are two objections to this hypothesis. One is that primary bone tumors mostly afflict the young, and there should be more evidence of neoplastic processes in the available skeletal collections. The other is in the possibility that we are not recognizing mummified tumors. In my study, malignant tumors were actually found to be better preserved by mummification than normal tissues. The pattern of replacement of normal structures, upon which the pathologist depends, is well preserved. The enlarged hyperchromatic nuclei of malignant cells retain these characteristics with mummification, remaining visibly larger and darker than adjacent normal nuclei. This contrast was well seen with lung and breast tumors and metastases to the bone marrow and liver. Most of the tumors examined were adequately preserved and a number of metastatic

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tumors could be identified as to the tissue of origin. The exception was tumors of the gastrointestinal tract, where digestive enzymes result in autolysis. The identification of metastatic adenocarcinoma in lung, liver or bone may supply our only inference as to occurrence of such intestinal tumors. My diagnosis of a rectal carcinoma, an area free of these hazards, is the only report of a tumor of this organ system in the literature (Chapter 7). This experimental study has been applied to other issues. Occasionally modern tissue specimens are accidentally dried out in the laboratory, due to processing machine failures or specimens simply being dropped or improperly fixed. These specimens can be rehydrated, examined, and valid diagnoses arrived at, thus saving patients the issues of a second surgical procedure. Another application is in an occasional problem encountered in forensic medicine, the finding of a mummified body preserved by chance in a dry or cold environment conducive to mummification. Such individuals have usually died suddenly in an obscure location, precluding their discovery and allowing time for natural mummification to take place. In the absence of evidence of trauma, it is important to establish a natural disease process such as arteriosclerotic heart disease to account for death. It is possible to dissect such mummified cadavers, rehydrate the tissues, and examine them microscopically. Examination of the cardiovascular system bears directly on the problem. While diagnosis of acute myocardial infarction (“heart attack”) remains problematic, as noted above, coronary atherosclerosis and/or thrombosis should be recognizable in mummified remains. The necrosis of muscle in an acute infarct is in essence a process of in-situ autolysis and an acutely infarcted area cannot be distinguished from adjacent autolyzed myocardium in a mummified heart. Diagnosis of an acute infarct in a mummified heart would have to be based the finding of the remains of a neutrophilic infiltrate, a problematic matter at best in the experimental setting and probably impossible in a naturally preserved mummy. Generalized atherosclerosis and coronary artery disease are readily demonstrable in ancient mummies, supporting this experimental study.

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Coronary thrombosis should remain a detectable lesion in the mummified heart when the appropriate PTAH stain is used. Myocardial interstitial fibrosis was recognizable, especially with the trichrome stain. A healing myocardial infarct showed a large area of fibrosis with peripheral organization by granulation tissue. With mummification, the fibrosis was seen as a lighter staining eosinophilic area with a decreased number of nuclei. Again, trichrome stain showed the fibrosis very well and the peripheral organization was also clear. The fibrosis of a healed infarct should remain detectable. Chronic passive congestion of the lungs, liver and spleen was well preserved in the experimental setting, particularly the hemosiderin pigment present, which retained a marked avidity for the iron stain. This evidence of chronic passive congestion resulting from a failing cardiovascular system proved to be preserved when an entire body was mummified experimentally in another study several years later (Chapter 8). The main purpose of my experimental study was to establish a baseline for future histologic investigations of mummies, making paleopathology a more useful tool for the examination of archeologic populations. The use of mummies in the establishment of disease patterns would require the investigation of a number of specimens large enough to be considered representative of the population under study. Identification of specific disease processes may prove helpful in explaining population changes and movements in the past. Suitable numbers of mummies do exist for at least two populations. Investigation of mummies from the American southwest could give us significant evidence, either positive or negative, on the role of disease factors in the population decrease in that area in the thirteenth century CE. Examination of Aleut mummies would provide information as to disease in this area before Russian contact. This data, combined with historical records, would give us a much clearer picture of the impact of outside contacts on the health status of an isolated community.

Chapter 6

EGYPTIAN MUMMIES IN MUSEUMS Four Egyptian mummies in the Penn Museum (formerly the University of Pennsylvania Museum of Archeology and Anthropology) were studied by a group that became the Paleopathology Association. The first mummy dissected in the University Museum series (PUM-I) was diagnosed as being afflicted by a disease, sub-corneal pustular dermatosis, first described in 1956 by Drs. Sneddon and Wilkinson as a process of sterile pustule formation on the abdomen and in the axilla and groin areas. Like many diseases, it must certainly antedate its first clinical description, in this case, almost 3,000 years ago. The mummified individual had been a middle aged man of moderate social and economic status, as judged by the external appearance of the wrappings. He had died during the 22nd dynasty (945-715 BCE.) Radiocarbon dating was performed on the wrappings. Fresh linens are known to be used for mummy wrappings, so the date of the linens is the date of death, in this case 892 BCE +/- 53 years. The results of the autopsy were initially quite discouraging, since it appeared that the body had merely been wrapped in linen, without going through the full mummification process. It consisted of a skeleton with some attached dry skin and muscle on the legs and trunk. The thoracic viscera were identified with some difficulty, while the abdominal organs

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were not seen. The tissues were rehydrated with Ruffer’s solution. Considerable difficulty was encountered, as the tissues showed a definite tendency to dissolve in the rehydrating solution. This problem is usually due to bacterial decomposition of the tissues, which proved to be the case. The few small fragments that remained to be sectioned consisted of masses of bacteria. An attempt to identify hepatitis antigens in tissue from the liver found only bacterial antigens present. Sections taken from the presumed heart, lungs, blood vessels, and kidneys showed no recognizable tissue. A section of skin from the upper medial area of the thigh showed a much greater degree of preservation, probably because of prompt desiccation. The stratum corneum, dermis and subcutaneous adipose tissue were identifiable. Just under the stratum corneum were multiple vesicles containing granular debris. These granules were of varying size and did not have a typical morphology of bacteria. Some did take the gram negative stain and this pattern represents a mixture of degenerated post mortem bacterial invaders and inflammatory cells, neutrophils. These lesions were not seen in skin sections from the back and were diagnosed by a consulting skin pathologist as sub-corneal pustular dermatosis. Impetigo was another possibility, as was pemphigus foliaceus, in which sub-corneal pustular lesions are occasionally seen. Previous studies have noted excellent preservation of mummified skin. A number of dermatopathologic conditions have been diagnosed in mummies including chicken pox (variola), comedones (pimples), decubiti (bed sores) and eczema. The distinction of such conditions from postmortem artifact in the specimens is always a problem, but in this case, several features were consistent with the diagnosis of sub-corneal pustular dermatosis. The sub-corneal location of vesicles was characteristic, as was their unilocular nature. This change was confined to the upper inner part of the thigh, as it generally is in modern patients. Sections from the back and scalp showed no such lesions and one would expect a post mortem change to be more diffuse. Impetigo, a bacterial infection, is also a more diffuse process and usually occurs in children. Staphylococci or streptococci, the causative organisms, are gram positive and the degenerative gram negative bacteria

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seen in the mummified vesicles probably represented terminal or post mortem invaders. Pemphigus foliaceous is an idiopathic condition that is histologically identical to sub-corneal pustular dermatosis, although older lesions are characterized by dyskeratosis of the cells of the granular layer. The degree of preservation in this mummy was not sufficient to evaluate this change and pemphigus can only be excluded by its usual involvement of most of the body surface. As is usual in paleopathology, not all of the criteria for diagnosis of this specific condition were satisfied but enough were present to make a tentative possible diagnosis. We diagnosed a case of sub-corneal pustular dermatosis that antedates the modern clinical pathological description disorder by over 28 hundred years. This finding is of importance to the modern clinician, in that it implies that there are other diseases afflicting people, both today and perhaps in the past, which have not yet been recognized as clinical entities. The second mummy of the series was flown to the Detroit Institute of Art for examination. This mummy had been wrapped in twelve layers of linen, over which hot liquid resin had been poured. It took seven hours of work with hammer and chisel to remove the wrappings. The skin and tissues were also glass hard and had to be cut with a Stryker saw. Four packages were found in the thorax and abdomen. Further studies showed that one contained spleen and some intestine and the other three contained lung. Parts of the aorta and heart were found still in place. The kidneys and urinary bladder were not seen. The penis was intact and was held in an upright position supported with a small piece of wood. The testes were missing, probably having been removed through the pelvis. The brain was missing, with the cranial cavity partially filled with resin. The individual was estimated to be between 35 and 40 years of age and his height approximately 162 cm. (5’4”). Small fragments of intestinal tissue found in one of the packages contained a single helminth egg, which was identified as Ascaris. The ova of this worm have been recorded in large numbers from prehistoric sites in Europe but this is the first report in Egypt. Ascaris eggs have been

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recovered only in the Old World and may have evolved as a human parasite after the separation of the Americas after the Ice Age. Possible source of parasites would be the ascarids of pigs, which were domesticated about this time. The other tissues proved to be very well preserved including the skin and eyes. The aorta showed atheromatous plaques; in the other organs found in the visceral packages, large and small arteries and arterioles showed areas of intimal fibrous thickening, typical of arteriosclerosis. The lung showed areas of fibrosis, within which there were deposits of anthracotic and silicotic pigment. The silica content of the lung was slightly above the upper limit of normal, indicating that this man had pneumoconiosis, probably from inhaling sand during desert dust storms. This finding seems to be the earliest case of silicosis. One odd finding was a non-specific chronic osteoblastic inflammation, periosteitis, along the distal half of the right fibula. There was no fibrosis seen in the soft tissue adjacent to the bone, which suggests that the periosteitis was not infectious in nature and perhaps this condition was related to varicose veins. Electron microscopic studies showed preservation of ultra-structural detail, but considerably altered by mummification. No pathologic changes were identified. Blood typing was done using vertebral bone and blood type B was identified. The teeth showed evidence of periodontal disease and occlusal attrition. The right ear drum was perforated, and the shape and appearance of the perforation suggested that it was the result of antemortem acute otitis media, as did evidence of chronic infection in the well preserved temporal bone. The perforation of the ear drum was the earliest known. The coffin that the mummy was in was of the Greco-Roman period but did not have the name of the deceased man on it. This suggests that the coffin was one that was simply taken out of stock rather than having been custom made and it must be kept in mind that it could be a later coffin. The technique of mummification also suggests that this is a later period mummy, particularly the careless packing of the organs. There were three packages containing lung and one containing spleen and some intestine, instead of lungs, liver, intestine and stomach being placed in separate

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packages. The body was not circumcised. These findings all indicated that the methods used were a debased form of those from an earlier period. The linen wrappings and all of the other evidence indicated that the radiocarbon date to the Ptolemaic period is correct. Another interesting finding was the presence of a small ball of cotton in the linen wrappings. This was the earliest finding of cotton in the Middle East, although it was in use in India 2,000 years earlier. This finding raised many questions about trade route connections between Egypt and India before the Christian era, as well as about the cultivation of cotton in Egypt. The bones were examined for heavy metal concentration, and the lead level was found to be 0.6 parts per million, a small fraction of the average level in modern bones (6 to 18 parts per million). The mercury level in the bones, however, was the same as that found in modern bones. Similar values were found in PUM-I. It was noted that the mummy deepened in color significantly within 24 hours and continued to do so for several weeks. We found this phenomenon to be a constant one in further mummy studies. Apparently intact protein of molecular weight corresponding to that of gamma globulin was found, raising the possibility that exceptionally well preserved bodies, such as by freezing, may provide material with biologically active antibodies. Identification of such antibodies would permit the identification of specific diseases. Probably the most important result of the autopsy of PUM-II was that it led to the formation of the Paleopathology Association, which has maintained a membership of several hundred individuals since. PUM-III was a young woman whose mummy had been prepared by stuffing the abdominal cavity with linens via the perineum. The viscera were compressed against the diaphragm and the packing extended into the chest through a defect in the diaphragm. This style of mummification had not been encountered previously in the PUM series or in any other mummies I have examined. The state of preservation was poor and only two pathologic diagnoses could be made. Clumps of anthracotic pigment containing refractive silica particles were seen in the otherwise decomposed lung. This anthracosis

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could be attributed, as in other mummies, to an open fire in the household. The silicosis was probably again due to inhalation during sand storms but this woman had not yet developed pulmonary fibrosis. A well healed rib fracture was present. The remodeling of the bone was not complete, indicating that the trauma had occurred at least several months before death and was probably unrelated to her demise. Owing to the poor state of preservation it was impossible to assign a specific cause of death for this mummy. The last of the series (PUM-IV) turned out to be a child in extremely poor condition. The wrappings were unusual, in that the mummy bundle was totally wrapped in what appeared to be a fish net, made of string in a square knot pattern. Inside this was an incomplete painted shroud, made of coarse linen, assembled from several pieces in an unusual patch work pattern. The area overlying the face was completely destroyed, so no painted portrait remained. Linen strips were wrapped around the body inside this shroud. The body itself was found to have been tied to a full length board, after having been dressed in a short tunic and three more shrouds. The impression received from these wrappings was that the mummy had been prepared from a content of the embalmers’ scrap bag. The dating appears to have been the Roman period, probably of the first or second century CE. X-Ray examination revealed several skull fractures, but there was no evidence of healing and these were probably post mortem artifacts. The age of the child was estimated to be about 8 years. As development of children in ancient Egypt seems to be about 2 years behind that of modern children, the proper age of the child was probably 9 or 10 yrs. The body of the mummy was very poorly preserved. The skin was full of holes with numerous small beetles and insect larva present throughout. The external genitalia were those of an immature uncircumcised male. There was a large defect in the rectal area that contained a 5 cm. wad of cloth and a large amount of granular material partially sealing the defect, implying mummification through the anus. When the chest and abdominal walls were removed, there were no recognizable organs in the cavities, which were filled with large masses of

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granular packing material, either mud or saw dust. Many insect larvae were also found. The only identifiable structures were markedly desiccated cerebral hemispheres and possibly the esophagus and trachea. The skull fractures noted radiologically appeared to be post mortem. There was no evidence of trauma or any other pathologic process and we were unable to determine the cause of death in this child, as microscopic study was totally unrewarding. The studies of the newly formed Paleopathology Association then moved on to the Royal Ontario Museum in Toronto. This autopsy of a 3,100 year old Egyptian mummy (dubbed ROM-I) was arranged by Dr. Peter Lewin and involved a total of 47 physicians, anthropologists and other scientists. The exact date of the acquisition of the coffin and mummy of this individual, whose name was Nakht, is not known. The tomb in which Nakht was found was discovered in 1904 and it is presumed that the mummy arrived in the Royal Ontario Museum some time shortly thereafter. The site of discovery was Deir el-Bahari, across the Nile from modern Luxor. The funerary temple of Mentuhotep II, a king of the 11th dynasty (about 2,010 BCE) was being excavated. All the tomb chambers in the temple area had been robbed in antiquity and many had been used in later times by humbler people. In one of them the coffin of Nakht was found. The anthropoid coffin was gaily decorated with scenes and inscriptions and although there was considerable damage, it could be determined that the owner was a male named Nakht, described as the “weaver” of the Kny temple of one of the kings of the 20th dynasty. This king, Setnakht, died about 1198 BCE. His son Ramses III, established a funerary cult for his dead father, which was carried on in a mortuary chapel of a type called Kny, a word meaning something like carrying chair or sedan chair. The name seems to refer to either a statue of the deceased God King in a sedan chair or an empty throne-like chair over which the spirit of the dead ruler was thought to hover. The style of the coffin suggested that it was made in the first half of the 12th century BCE. From the archeologist’s point of view this mummy was a natural choice for autopsy, as there was a good

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account of its discovery and excavation. The inscriptions and style of the coffin provided unusually clear evidence of its date. The simple title weaver showed that Nakht was of the laboring class and was far more representative of the great mass of the ancient population than most mummies, which tend to be of persons in the middle classes or the aristocracy, who could better afford the considerable expense of a traditional Egyptian burial. Finally, we are probably better informed about his times, the last century of the New Kingdom, characterized by political confusion, moral uncertainty and spiraling inflation, than we are about any other period of Egyptian history. Nakht’s lower class family apparently had been able to afford a relatively fine coffin because he had not undergone the expensive process of mummification but had simply been washed and wrapped in linen. The good preservation of his body was due entirely to the dry and stable Egyptian climate. By omitting mummification his family had been able to spend more of their presumably slender resources on the coffin. The cost of decorating such a coffin in Nakht’s day was approximately one ounce of silver, representing as much as ten percent of a working family’s income. Although the body had been carefully wrapped in linen in the traditional manner, the amount of linen used was noticeably less than in many mummies of the period. The bandages were in very good condition and came away easily chiefly because none of the usual oils and resins had been poured over the body. It is probable that the family had wrapped the dead young man themselves, although the manner in which the bandages and filling pads had been arranged suggests familiarity with ritual customs. The wrappings were well preserved everywhere except in the area of the head, where they had broken through entirely, probably because of a collapse of the underlying cranial bones. Included in the wrappings were two of the large sleeveless tunic-like robes seen in wall paintings and sculpture of the period as the characteristic male custom. Their size was about right for Nakht and these were probably his clothes. While we don’t know anything specific about Nakht’s living conditions, his diet and general standard of living must have been better than those of most of the peasant cultivators that composed the bulk of the population, as he was in

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the upper ranks of the working class. In addition he enjoyed security derived from being attached to a permanent and prestigious institution, which may have exempted him from military service or forced labor and probably also protected him from the economic troubles of the times. Extensive radiological surveys done of Nakht before and after autopsy indicated that he was a male teenager somewhere between 14 and 18 years of age. Harris lines were seen in the left knee, suggesting malnutrition or episodes of infection or some kind of recurrent illness in the last two years of life. The other findings were that the wisdom teeth were well developed but un-erupted, indicating an age under 18, and that the organs of the abdomen and chest were in place, with an intact diaphragm. The plaque often seen over an evisceration wound was not seen. While the skull sutures had separated and the vault bones had fallen in, the bones in the ethmoid area had not been perforated to extract the brain. Between the shrunken tissues and the wrappings was an air-containing gap up to 4 cm across, indicating that desiccation had occurred after wrapping. The radiological examination gave no evidence that Nakht had been eviscerated or even embalmed but had been desiccated naturally in the dry hot air of Upper Egypt. There was no radiological clue to the cause of the death other than the Harris lines. The gross dissection of Nakht was done by myself and two other pathologists with the assistance of two anatomists from the University of Toronto. The dissection was recorded by a color movie and still photography and tissues removed from the mummy were recorded and photographed. The unwrapped body showed the head and facial features had disintegrated and the skull bones had collapsed giving the torso the appearance of decapitation. The body showed no evidence of artificial preservation and was firm to the point where it could be lifted like a board. The intact body weighed only 5 kg and the overall length was 143 cm. The air gaps between the wrappings and tissues that had been seen radiologically were verified upon unwrapping the mummy. The skin was light brown and tough and leathery. The finger prints, toe prints, fingernails and toenails were very well preserved. The autopsy began with a study of the badly damaged head and neck area, including

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preservation of the skull bones. The skull was subsequently reconstructed. There were some areas still preserved, including the scalp, eyelids and eyelashes. The teeth showed some wear but were well preserved and did not show evidence of caries. Three of the teeth had become dislodged and were later retrieved from elsewhere in the wrappings. The remnants of the brain were recovered and appeared to be the cerebral hemispheres, each one weighing about 65 grams. The convolutions were preserved and examination by CT scanning showed preservation of the ventricles. The sigmoid sinus was identified and material suggesting dry blood was adherent to the internal lining. The anterior thoracic and abdominal walls were removed, using a Stryker saw. In the chest, the pericardium appeared as a tent tethered between the sternum and thoracic spine. The lungs had collapsed posteriorly and it was not possible to distinguish the upper and lower lobes, which were gray black and powdery. The heart was removed and with the thoracic aorta and great veins weighed 17.7 grams. The trachea was identified and removed with the thyroid cartilage. The diaphragm was intact and was dark brown, firm and leathery. It was cut around the periphery and removed. In the abdomen, the liver was shrunken, but had retained its shape and a sharp lower border. It weighed 106 grams. Portions of the gall bladder were removed. The spleen was present and, in comparison to the amount of shrinkage of other organs, appeared to be enlarged. It was crumbling and could not be weighed in toto. The posterolateral wall of the splenic bed showed dark discoloration, possibly representing hemorrhage from a splenic rupture. The intestines were present but were paper thin and collapsed. The bladder was also present, as a sac-like hollow structure 6 cm. in width. The prostate was not identified. The rectum was extremely fragile and removal of the posterior wall of the pelvis demonstrated the sacral plexus, which was well preserved. The penis was uncircumcised. The scrotum was identified, but testicular tissue was not found. Histologic examination was performed after rehydration of the various tissues in Ruffer’s solution. Small cyst-like structures were noted in the intercostal muscles. In the lungs the alveolar architecture was partially

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preserved and there was substantial deposition of anthracotic pigment within the connective tissue. On examination with polarized light we noted bright birefringent particles throughout the tissue. However, silica analysis of lung tissue yielded normal findings. X-ray diffraction analysis with an electron microscope microprobe indicated that these particles were granite. Muscle coats of the intestinal tract at various levels were well preserved. The lumina of both large and small intestines contain numerous ova of both tinea (tapeworm) and schistosomal species. Some of the schistosome ova had large terminal spines. No adult worms of either type were seen, but the tinea ova were clumped, suggesting the site of a degenerated proglottid. The bladder contained remnants of epithelium. There were no ova or changes suggesting inflammation but a few well preserved erythrocytes on the mucosal surface suggested hematuria during life. The liver showed cords of indistinct hepatic parenchyma and a fibrous pattern of early cirrhosis, with formation of small nodules. Portal areas contained calcified schistosome ova with terminal spines similar to those noted in the intestinal lumina. The spleen was poorly preserved and showed heavy postmortem bacterial contamination. Sections of the heart were normal, but several schistosome ova were seen in the kidney. A number of special studies were done on the tissues in addition to histologic examination. Bacterial cultures of various samples yielded no growth. Electron microscopic studies of liver tissue did not demonstrate virus particles and radioimmunoassay of liver tissue was negative for hepatitis B antigen. Computerized axial tomography (CAT) scan of the intact brain showed preservation of the gray and white matter and the lateral ventricles. There was no evidence of tapeworm involvement of the brain. Examination of the ears showed that the ossicles were intact although grossly displaced, probably a postmortem change as there was no pathologic abnormality present in the ears. In summary, postmortem examination of this 3,200 year old mummy of a teenage Egyptian boy revealed a variety of disease processes. He had at least two types of parasitic infection, both of which must have produced severe complications. Numerous ova of Tinea species were found within

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the intestinal tract. Since the ova of T. solium, the pork tapeworm and T. saginata, the beef tapeworm, cannot be differentiated and no scolex (head) was found, no final decision could not be made concerning the species of the parasite. The small cyst-like structure in intercostal muscle may represent cysticerci, the disseminated encysted larval forms of T. solium but histologic detail was lacking. The differential diagnosis was between cysticercosis and trichinosis. Cysticercosis would probably have been due to T. solium, although massive T. saginata infestation has been reported as a cause of cysticercosis. It is also possible that 3200 years ago cysticercosis was a more common feature of beef tapeworm infestation. The finding of tapeworm ova does imply that Nakht ate meat, probably which was not well cooked. Meat fibers had been found in the intestine of other mummies, so ancient Egyptians were probably not strict vegetarians. The malnutrition associated with this parasitic infestation probably contributed to Nakht’s death and the presence of Harris lines in the leg bones supports this thesis. Further study of the cysts in the intercostal muscles suggested that this was due to trichinosis, as the cysts were too small, when compared to the adjacent muscle fibers, to be cysticercosis. Trichinosis is, however, like cysticercosis, due to the eating of inadequately cooked pork and either diagnosis has the same implication of access by Nakht to meat. Many schistosome ova were found in the GI tract, several with large terminal spines characteristic of Schistosoma hematobium and others without obvious spines that may have been degenerated forms or ova of S. mansoni. Both forms of schistosomiasis are endemic in modern Egypt, and S. hematobium infestation has been reported in other Egyptian remains. There was evidence of early cirrhosis of the liver and congestive splenomegaly, possibly with terminal rupture. Schistosome ova were found in the liver, which suggests that the cirrhosis was secondary to hepatic schistosomiasis, most commonly due to S. mansoni, although S. hematobium can result in the same histologic picture in the liver. The calcified ova found in the kidney and the presence of erythrocytes in the bladder indicated involvement of the urinary system with S. hemotobium. Schistosomiasis remains a chronic debilitating disease in

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Egypt and there is no sign of adaptation between man and parasite in this geographic area. As the disease is easily transmitted, there is no incentive for the parasite to develop a more symbiotic relationship with its human host. An incidental finding, present in all ancient remains, was pulmonary anthracosis, secondary to environmental pollution by cooking and heating fires and by oil lamps in small quarters. It also appeared that Nakht had granite particles in his lung due to inhalation of dust and sand, perhaps while working near or at a stone quarry or workshop. Electron microscopy was done on several tissue specimens. Skin from the foot showed excellent preservation of the epidermis and cellular components. One of the Tinea eggs was studied and the ultrastructure was seen to be well preserved, including the hooklets of the larvae. An erythrocyte found in the intestinal contents was photographed with a scanning electron microscope. There was thus preservation even at the ultrastructural level in this mummy. Biochemical analysis of the Nakht’s tissue showed that he had not been treated with natron or other salts, since the concentration of cations was approximately the same as that of freshly autopsied human skeletal muscle. Much of the high molecular weight protein in the body was found to have undergone degradation, in contrast to mummies treated with natron, who show good preservation of the these large proteins. Blood group analysis was considerably complicated by bacterial contamination of the tissues but material from the sigmoid sinus, considered to be dried blood, showed a positive reaction for blood group B, using two techniques, the serologic micro method (SMM) and the inhibition agglutination test (IAT). Blood group substances are complex carbohydrates that may be separated from erythrocytes and may be detected after erythrocyte disintegration. Forensic scientists have developed techniques for identifying the blood groups of dead persons and those of blood and tissue stains found during the course of criminal investigation. The SMM and the IAT used in such investigations are also applicable to the study of ancient materials; Connolly and Harrison used the SMM to investigate the kinship of the ancient Egyptian kings

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Smenkhare and Tutankhamun. With the SMM, A or B antigens are absorbed to fresh group 0 human erythrocytes. The presence of these antigens can be demonstrated by the microscopic agglutination produced by specific anti-sera. With the IAT, which detects minute amounts of blood group substances, the ability of an unknown material to inhibit known specific anti-sera is assessed. For example, if a sample of unknown blood group contains B antigen and is combined with anti-B serum of known potency, some of the anti-B will be bound by the antigen and will produce a measurable decrease in the potency of the remaining anti-B serum. With both the SMM and IAT caution is needed in the detection of blood group 0. If with the SMM no agglutination occurs with anti-A or anti-B serum, the lack of reaction may be due to either the presence of group substance or the absence of any antigenic material. With the IAT the unknown sample is adsorbed with H antigen (a precursor blood group antigen present in highest quantity in 0 cells). Blood group 0 is suggested when there is a decrease in the anti-H potency without change in the anti-A or anti-B activity. Splenic material and the dark brown substance from the inside of the sigmoid sinus of Nakht were tested with the SMM and IAT. Repeated testing of the splenic material with the SMM produced no agglutination and the procedure was complicated by hemolysis of the adsorbed group 0 cells. However, when the splenic material was tested with the IAT a positive result for blood group B was obtained. The sigmoid sinus material showed a positive reaction for blood group B with both the SMM and the IAT. We had no explanation for these results until we studied histologic sections of the spleen and the sigmoid sinus. The splenic material was heavily contaminated by bacterial and fungal spores that were hemolytic to the group 0 test cells. Hence the presence of B antigen in the splenic material could not be demonstrated by adsorption to group 0 cells, but was detectable by the IAT. Histologic sections of the sigmoid sinus showed excellent preservation of erythrocytes and absence of bacterial spores. When tested, this material gave a good source of blood group antigen and the tests were not negated by contaminating hemolytic spores.

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Our observation of intact erythrocytes for many centuries was not the first. I reported preservation of intact erythrocytes in the pulmonary vein of a naturally preserved 2000-year-old American Indian mummy. The erythrocytes isolated from Nakht in our study were the oldest known preserved human blood cells. The histologic findings made us confident that our testing techniques were bona fide and that Nakht’s blood group was B. Finally, the Paleopathology Association contributed the following epitaph: There was a young weaver called Nakht, Whom disease severely attakht. When he finally died, They dried out his hide, But left all his organs intakht.

Chapter 7

THE DAHKLEH OASIS PROJECT In 1992, an archeologic expedition by the Royal Ontario Museum and Canadian Institute for the Study of Egyptian Antiquities invited me to examine mummies found during the excavation of the ancient city of Kellis, in the Dakhleh Oasis in the western desert of Egypt. The Dakhleh Oasis Project is jointly sponsored by the Royal Ontario Museum and the Society for the Study of Egyptian Antiquities, Toronto, Ontario, Canada and is largely funded by the Social Sciences and Humanities Research Council of Canada. The site was occupied from the 1st to the 3rd century CE, the time of transition in Egypt from the traditional religion to Christianity. Egypt remained Christian until the Moslem conquest of 641 CE but Kellis had been abandoned some 300-400 years earlier, presumably because the water ran out (wells in the area, now referred to as the New Valley, are as much as 300 meters deep). The site consists of the remains of numerous mud brick buildings, both freestanding and partially buried in the sand, including a church. The town covers a square kilometer and the population was probably several thousand. Surrounding the town are numerous low hills, 20-30 meters high. At their bases are tombs, visible as sand filled depressions.

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The Dakhleh Oasis Project has been engaged since 1978 in an interdisciplinary study of the relationship between human activity and environmental change in this site in the western desert of Egypt. The time frame under study is mid-Pleistocene to the present (some 500,000 years) and the team consists of prehistorians, historical archeologists, geologists, zoologists, botanists, physical anthropologists, paleopathologists and others. Previous paleopathologic findings have included evidence of hyperparathyroidism, trephination, fluorochrome labeling in bone and leprosy. Expedition members usually took the train from Cairo to Assiut, were met there and then driven on to the oasis. My wife Barbara and I were driven from Cairo, the train not being an option because of Islamic terrorists, who were shooting at the first class cars. There is a beautiful new highway through the desert on the east side of the Nile, so we had a very quick 200 mile trip to Assiut. As we neared Assiut we acquired an escort of several open back trucks filled with military police armed with assault weapons, with some aimed at us! Bobbie told me to take their picture, but I pointed out, “one never points anything at someone with a gun!” The MPs led us through Assiut, with the streets lined by Egyptians in galabiehs, traditional Arab garb, with rifles slung over their shoulders. We wondered whose side they were on! As the soldiers departed with assurances of safety, we went on into the desert, where we could see telephone poles sticking up out of the sand several hundred yards parallel to the road. Sand had drifted almost to the tops of the telephone poles, forcing rerouting of the road. After 10 hours we arrived in el Bashendi, where the expedition had rented a mudbrick house across the street from the Mosque. When we asked for the toilet, the reply was “Do you want the one with the door?” a second floor room with a hole in the floor and lots of flies. That evening, we were driven to the local private bath, a hot spring where the expedition members climbed in, turned their backs and took baths. Our house had no running water and our drinking water, from one of the local wells, was drip filtered. Our room featured mats on the dirt floor, a bare light bulb and a

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“closet” - hooks in the wall. The electricity was produced by a local gas powered generator that went off at 10 pm. The town of Kellis was abandoned in the 3rd century CE. The site consists of the remains of numerous mud brick buildings, both freestanding and partially buried in the sand, including a church. The town covers a square kilometer and the population was probably several thousand. Surrounding the town are numerous low hills, 20-30 meters high. At their bases are tombs, visible as sand filled depressions. For the first few nights, sleep was interrupted only by the call to prayer from the Mosque every four hours. We soon adapted to sleeping straight through, a good thing, as we had to get up at 5 each morning. In April in the Western Desert, it gets much too hot to work outdoors after lunch. The entrance to the tombs containing the mummies we were to be studying had been covered with sand, in order to keep tomb robbers out. Our workmen shoveled the sand off and opened the first tomb. Quite a sight was revealed, intact and fragmented mummies filling a small cave-like tomb, not quite the “remarkable things” greeting Howard Carter in Tutankhamun’s tomb but very exciting to us. The workmen then removed the mummies. The archeologists, used to working in the sand on their knees, seemed to be amazed at my makeshift autopsy table, a couple of sawhorses and a board, and my principal tool, a foot long dissecting knife. I spent the morning examining several of the mummies and we were then back to the spring and early to bed. The next day I developed another innovation, using the tailgate of the expedition’s Land Rover as an instrument tray. We tried bringing the mummies back to el Bashendi and working in the house, but there were too many flies, so working out in the open in the desert was a better choice. Fourteen mummies, removed from two tombs, were photographed, unwrapped and subjected to postmortem examination. Gross pathology was noted and samples taken of all organs and structures identified in the mummies. Back in my Philadelphia laboratory, the tissue samples were rehydrated in Ruffer’s solution, paraffin embedded and examined by light microscopy. Pathologic change was identified in seven of these mummies,

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which came from 3 different tombs, labeled by the archeologists as the West Cemetery, Tomb 2 and Tomb 6. West Cemetery Body A was the trunk, arms and thighs of a child. The total length was estimated at 100 cm, consistent with an approximate age of 6. Defects were noted in the chest and abdominal walls and only fragments of the left lung, intestine, liver, and rectum were identified. On microscopy, the left lung revealed degenerating homogeneous eosinophilic material with very little residual lung structure. The color suggested hemorrhage and there was scattered anthracotic pigment. The other viscera were poorly preserved and the only pathological diagnosis was anthracosis. West Cemetery Body B was a 163 cm adult male with a scanty amount of red-brown hair and linen plugs in the orbital cavities. The dentition was intact, showing a moderate amount of wear consistent with an age of approximately 30-40 years. There was a fragment of anthracotic lung in the right pleural cavity. Tissue samples were taken from the base of the neck, lung, rectum, penis, and scrotum. Microscopic examination of the right lung revealed collapsed lung tissue with a moderate degree of anthracosis. Several larger aggregates of anthracotic pigment appeared to represent lymph nodes. Small blood vessels and fragments of bronchial cartilage were also seen. The tissue from the base of the neck showed poorly preserved anthracotic lymph nodes. The rectum contained fragments of degenerate vegetable matter admixed with several calcified and degenerate ovoid masses. A terminal spine was seen in one, diagnostic of the parasitic worm Schistosoma hematobium. Numerous large blood vessels were identified in the penis and the tubular architecture of the testis was preserved. Pathological diagnoses were anthracosis, involving the lungs, pulmonary and cervical lymph nodes and schistosomiasis involving the rectum. West Cemetery Body C was a 168 cm adult male with curly black hair, a full beard and mustache and linen plugs in the orbital cavities. The heart and aorta were identified and samples were taken of the rectum. Examination of the heart and aorta revealed degenerated myocardium and a mild degree of aortic atherosclerosis with cholesterol clefts identified. The rectal wall was well preserved with a polypoid mass on the mucosal

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(inner) aspect, showing relatively well preserved overgrown colonic mucosa in a tubular pattern. The nuclei were not preserved but the central portion of the lesion showed deep invasion into the underlying muscularis. Special stains revealed that the cells were clustered in the pattern of epithelial cells. This lesion was consistent with an infiltrating adenocarcinoma arising in a benign tubular adenoma. Multiple round and ovoid calcified structures, 40-70 microns in diameter, were noted in the muscularis and adventitia. Several underlying the adenoma were consistent with calcified schistosome ova but spines were not seen, precluding speciation. Pathological diagnoses were mild aortic atherosclerosis, an infiltrating adenocarcinoma of the rectum arising in a benign tubular adenoma, and schistosomiasis involving the rectum. Tomb 2 Body I was the torso of an apparent adult male, although the pelvic area was absent. The thorax was intact. No internal organs were identified. Three fragments of fecal material were seen in the area of the splenic flexure of the colon. On microscopy, mixed with degenerating vegetable matter, bone and fragments of colonic mucosa were large fragments of long uneven muscle fibers with remnants of a surrounding cuticle, which stained positively with PAS. The pathological diagnosis was possible Ascaris lumbricoides infestation. Tomb 2 Body M was a headless but otherwise complete dirt encrusted male body measuring 150 cm from the neck to the heel. Anterior bowing of the right mid tibia was noted, with marked shortening of the right lower leg, measuring 40 cm from the lower border of the patella to the heel, 6 cm shorter than the left. The deformity of the anterior bowing was approximately 1.5 cm. There was a marked deformity of the right foot, in a talipes cavus (club foot) configuration, with elevation of the arch and curling of the lateral 4 toes. The right heel pad was markedly thickened, measuring 2 cm in external thickness as compared to 1 cm for the left pad. Specimens were taken of tissue of the heels. The right chest wall was extensively damaged, with multiple defects up to 4 cm in diameter. The anterior thoracic and abdominal walls were removed and the body cavities were noted to be completely filled with dirt, sand and small pebbles. The heart was identified and sampled. A heart

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valve, probably the mitral, and the aorta could be recognized. The abdominal aorta showed fragments of atherosclerotic plaque, vessel wall and degenerating blood. The right lung was grey-tan, suggesting anthracosis. Impressions of the ribs were noted on the posterior aspect of the lung, suggestive of emphysema. The left lung was partially adherent to the lateral chest wall. Immediately below the diaphragm, the liver was identified and sampled. The remaining intra-abdominal organs were removed. Specimens were taken of the small and large intestine, abdominal aorta, urinary bladder, and rectal wall. Spinal osteophytes in the lumber region and mild scoliosis were noted. The right lung showed a generally consolidated architecture, with loss of alveolar structure and a hepatized appearance, suggesting pneumonia but more likely due to autolysis, as there is no evidence of any inflammatory infiltrate. Many bacteria were scattered throughout. There was severe diffuse anthracosis, with black pigment in the lung and in perivascular and peribronchial lymphatics. The alveolar architecture of the left lung was slightly better preserved than the right, but areas of anthracosis, consolidation and bacterial invasion remained prominent. Enlarged peribronchial anthracotic lymph nodes were seen, some containing sclerotic areas lacking anthracotic pigment and with needle shaped clefts, appearing to be old necrotizing granulomas. Acid fast stain, used to diagnose the bacteria of tuberculosis, revealed several diagnostically positive staining rods. Numerous gram positive and negative cocci (postmortem invaders) were also seen. The liver showed identifiable portal areas and parenchyma, but the general architecture was somewhat collapsed by autolysis of the hepatocytes. The portal areas were intact. Extending from the area of the central veins were numerous fine fibrous bands, which extend into the surrounding parenchyma, encircling individual hepatocytes. No parasite ova were seen in the portal areas. The general pattern of the fibrosis and the absence of ova suggested an alcoholic pathogenesis. An attached portion of stomach was fairly well preserved, with a recognizable mucosal pattern.

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The muscularis of the intestine and the villous architecture of the mucosa were moderately well preserved. However, the mucosa itself was not preserved. The muscularis and mucosa of the colon and rectum were poorly preserved but recognizable. The rectal contents showed vegetable matter, fungi and amorphous debris. No parasitic organisms or ova were seen. The wall of the urinary bladder was fairly well preserved, including the seminal vesicles. The mucosa was not preserved, except for a small papillary excrescence, within which basophilic (dark staining) nuclear material was seen. A reticulin stain was consistent with an epithelial tumor, showing small clusters of cells surrounded by reticulin. No parasites were seen. Microscopy of the skin of the right heel showed fragments of hyperkeratotic material with underlying fibroadipose tissue, within which were seen several cystic structures lined by dense fibrous membranes and containing granular eosinophilic material. These may have represented dilated lymphatics. The left heel showed a lesser degree of hyperkeratosis. Pathological diagnoses were talipes cavus, right foot, with shortening and bowing of right lower leg, lumbar osteophytosis, mild scoliosis, papillary transitional cell carcinoma of bladder, pulmonary tuberculosis, anthracosis and centrilobular hepatic fibrosis, possibly secondary to alcoholic injury. Tomb 2 Body N was the torso and lower extremities of a neonatal (newborn) child, with an estimated total stature of approximately 55 cm. Most of the anterior thoracic wall was previously destroyed and only a 2x1x1 cm fragment of right lung was identified. Protruding from the lower midline of the abdomen was a 2 cm length of what appeared to be umbilical cord. The abdominal organs were not preserved. The right lung showed residual alveolar architecture with degenerating blood filling the alveoli. There was no anthracosis. The umbilical cord contained sclerotic thick walled blood vessels. The pathological diagnosis was neonatal pulmonary hemorrhage.

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Tomb 6, body C was a heavily resinated adult male with a small amount of red hair present. The legs were absent. The orbital contents, thyroid gland and vessels from the neck were sampled. Examination of the orbital contents revealed adipose tissue containing dense eosinophilic material with multiple round defects containing lighter staining eosinophilic defects. These structures could have represented the lens, perhaps cataract formation, although it was possible that the cystic changes were a drying artifact. The thyroid gland consisted of masses of brown homogeneous material, within which were recognizable outlines of thyroid follicles. The epithelium was not preserved. A large artery showed intimal clefting suggestive of atherosclerosis. Pathological diagnoses were possible cataracts and possible atherosclerosis. We had spent a week examining a total of fourteen mummies but over a last lunch we discussed the risks of staying in a country that appeared to be on the verge of civil war. We had enough specimens to keep me busy and decided to go home the next day, before conditions deteriorated even further. The military police would not let us take the new desert road back to Cairo because of snipers, so we took the narrow old river road along the Nile. Traffic included trucks, triple trailers, buses, cars, camels, donkeys and carts, goats, motorcycles, and pedestrians. Near Cairo, the exhaust system fell off. We pulled off to the side of the road and the driver and I wired the system up. In the next town, the local “Midas Muffler” mechanic (who appeared to be a 12 year old boy) welded the offending parts back together. We were sitting in the back seat with smoke coming from under the hood but in Allah’s hands we stayed in the car. We were now on our way at night. Egyptians drive in the center of the road and cut the curves. They don’t use headlights; if they burn out, a replacement may not be available. At the airport hotel I walked up to the counter, dirty, unshaven and exhausted and told the clerk, “We need a room!” Ten minutes later we were in a clean room with a real bathroom. The next morning we got two of the last available seats for home. The specimens were wrapped in aluminum foil and packed in my luggage;

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luckily, nobody looked. After we got home, another member of the expedition called me. Things had gotten worse; they had a bigger escort and were told that all Americans were being evacuated. In summary, the Dakhleh Oasis mummies showed a significant range of pathology, encompassing most of the categories of disease found in modern populations. An adult male had a congenital disorder, talipes cavus (club foot), with a markedly deformed leg. One can speculate that the resultant discomfort led to self-medication by alcohol and the subsequent alcoholic cirrhosis observed in this mummy. It is known that the western oases had a well-developed wine industry. Infectious disease was also seen. The unfortunate individual with club foot also suffered from pulmonary tuberculosis. Parasitism included two cases of schistosomiasis and one possible case of ascariasis. Vascular and degenerative changes included atherosclerosis in two mummies and cataracts in one. Two of the adults and one of the children showed pulmonary anthracosis, continuing the documentation of that disorder’s geographic and temporal ubiquity. The other child showed neonatal pulmonary hemorrhage. Malignant tumors were diagnosed in two of the mummies. Based on my experimental studies of mummification (Chapter 5) indicating that mummification preserves the features of malignancy, tumors should be well preserved by the mummification processes practiced in ancient Egypt, as well as by processes of artificial and natural mummification seen in other areas in the world. The findings from the Dakhleh Oasis have confirmed the experimental studies indicating that mummification preserves the diagnostic features of malignancy. In ancient societies lacking surgical intervention, evidence of cancer would be expected to remain in all cases. Strouhal cited a total of 131 cases of cancer in Old World remains, 56 of which he considered doubtful. Malignancies diagnosed by gross examination of ancient skulls, primarily oral and nasopharyngeal carcinomas, are lesions seen commonly in underdeveloped countries today. Such ancient cancers may indicate a baseline incidence in antiquity, with

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implications for environmental etiologic factors in the modern industrialized and tobacco using world. The Dakhleh Oasis findings are also of archeological significance. The traditional view of trade in dynastic Egypt assumes that Nile River traffic navigated downriver, north, with the current and then south by sail power. Alternatively, traffic flowed down the Nile and then south through the chain of oases in the western desert. There is philological and archeological evidence of traffic, both military and commercial, between the western oases and the Nile Valley throughout Pharaonic times. The evidence found in the oases is primarily from the Old Kingdom, while evidence from the Nile Valley is Middle and New Kingdom. There is an incomplete cycle of hosts for schistosomiasis of the intestinal and urinary tracts in the Dakhleh Oasis, the intermediate snail host not being present in the desert. The two Dakhleh Oasis individuals whose mummies revealed schistosomiasis must have been in the Nile Valley for some period, perhaps stationed in a military garrison or as part of the Nile River/western oases trade circuit. Direct travel from the Nile to the Dakhleh Oasis (some 200 miles of totally arid desert) was possible but much less likely. The identification of schistosomiasis, a disease of the Nile Valley that is exotic in the desert, is confirmatory evidence of traffic between the two areas extending into the early Christian era.

Chapter 8

AN EGYPTIAN MUMMY IS MADE IN BALTIMORE Interest in the examination of Egyptian mummies has seen significant growth with the efforts of The Paleopathology Association, the Paleopathology Club of the U.S.-Canadian Academy of Pathology, and individual researchers. Experimental studies of mummification had been limited to the desiccation and examination of small fragments of tissue (Chapter 5), in which preservation was noted to be somewhat better than in actual mummies. There have been many reports of histopathology identified in Egyptian mummies but the unanswered question was whether the appearance of the tissues of these mummies was due to the effects of the Egyptian mummification process alone or was modified by the passage of the several millennia following the labors of the ancient embalmers. A donated adult male cadaver was mummified in Baltimore at the University of Maryland Medical Center by Bob Brier and Nicholas Wade in a fashion as closely as possible approximating ancient methods in an effort to answer this question. The ancient Egyptians practiced mummification for more than 3,000 years. During that period, new techniques were introduced, old ones were refined, and, during Egypt’s final decline, earlier procedures were forgotten and lost. Herodotus mentions that during the period he visited

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Egypt (circa 450 BCE) there were three different mummification procedures according to price. All Egyptian mummifications were clearly not the same. In the modern mummification, the intention was to replicate a first-class mummification of the period at which the embalmers’ art was at its peak. A royal mummification of the eighteenth dynasty was thus attempted. The donor, an elderly male, had died on the fifth day of hospitalization of heart failure and a clinically diagnosed massive myocardial infarction. The body was kept refrigerated for 36 hours and then placed in a freezer until removed for the study. The evisceration of the body was performed over a 16 hour period at room temperature (700 F) using a replica handmade embalming board and copper, bronze, and obsidian tools that had previously been prepared. Replicating ancient embalming technique, the body was eviscerated, not without some difficulty, through a small left lower quadrant abdominal incision, removing the spleen first and the liver last. The heart and brain were not examined in this study. In antiquity, the heart was left in the bodies, as part of the funerary ritual (Chapter 1). As the ancient Egyptians were unaware of the function of the brain, it was discarded after extraction through the cribriform plate of the ethmoid bone or the foramen magnum. In this study, a hook was inserted through the nose in order to pulverize and remove the brain. Natron (273 kilograms) had been imported for the study from the Wadi Natrun in Egypt. Natron is a naturally occurring compound of sodium carbonate and bicarbonate, with sodium chloride and sodium sulphate present as impurities. Twenty-nine 87 gram linen packets of natron were used to pack the thoracic and abdominal cavities. A layer of natron was placed under the body on the board, and the remainder of the natron was used to cover the body, incidentally making clear the necessity for a wide embalming board. The internal organs removed in this procedure, consisting of lungs, stomach, liver, spleen, pancreas, intestines, and kidneys, were placed in ceramic dishes, covered with natron, and placed at the corners of the embalming board. The cadaver and organs were than kept in a room at 115o F and 28– 30% humidity for 35 days.

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Historical information indicates a period of 30–40 days for embalming. After 35 days, the body had a strong odor but not one of putrefaction. The natron formed large hard clumps, stained dark brown. Removal of the natron revealed a body appearing very similar to an ancient mummy. The skin was dried and dark brown, almost black. The limbs were initially flexible but became rigid and inflexible later. The facial features were shrunken but essentially unchanged. Some moisture did remain in the most dependent parts of the body, indicating that more natron should have been placed under the body. The eviscerated body had weighed 70.9 kg, and when removed from the natron it weighed 35.9 kg, a fluid loss of almost exactly half the body weight. The separately desiccated internal organs were completely dehydrated. The liver, although not brittle, was flat and nearly inflexible. There was no evidence of decomposition or putrefaction, and cultures of the mummified outer and inner body surfaces and the viscera for bacteria, fungi, and viruses were negative. Small (3 cm in the largest dimension) tissue specimens of the lung, liver, spleen, kidney, stomach, small intestine, colon, and gluteus maximus were rehydrated in Ruffer’s solution for 36 hours, fixed in absolute alcohol for 36 hours, embedded in paraffin, and sectioned and stained by standard histologic techniques using hematoxylin and eosin (H&E) and several specific stains as noted below. As the pathologist in this study, I was not informed of the clinical history of the subject at the time I examined the tissue specimens. Sections of the liver showed the general sinusoidal architecture and portal areas to be intact, with fine periportal fibrosis evidenced by a trichrome stain. Nuclei were identified in many of the cells, varying from area to area. There was no evidence of primary or metastatic tumor. A few small bacterial colonies were seen. The other organs were variably preserved. The pulmonary architecture was generally intact. As is usual in mummified remains, nuclei were poorly preserved. A minimal amount of anthracotic pigment was noted in the alveolar septae and some of the alveoli contained pink proteinaceous material, which I diagnosed as the residua of pulmonary edema. Several large pulmonary arteries were seen to be filled with blood.

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Phosphotungstic acid hematoxylin (PTAH) stain showed a blue meshwork consistent with thrombus material, as I had previously reported in experimentally mummified thrombi (Chapter 5). The general architecture of the spleen was well preserved, including the capsule, red and white pulp and trabeculae. The kidneys were also well preserved, with glomeruli, tubules, vessels, and surrounding fat identified. An occasional thyroidized tubule was seen, suggesting old infection. The stomach was extraordinarily well preserved. The muscle wall and mucosa were intact, including the mucus-secreting glands of the stomach. On the other hand, the small and large intestines were poorly preserved, with loss of the mucosa and reduction of the muscularis to an eosinophilic mass. A section of the gluteus maximus showed poorly preserved muscle and fibroadipose tissue. Cross striations and nuclei were not seen with H&E stain and the striations were barely seen with PTAH stain. The general state of preservation of the organs in this experimental mummy was slightly better than but comparable to that of actual 1,800– 3,200-year-old Egyptian mummies. The experimental process of mummification appears to have resulted in good preservation of these organs, the histologic appearance being similar to that seen in my smaller scale experimental studies of mummification. The differential preservation of most of the organs was much the same as ancient mummies, in that the lung and kidney were well preserved, the gluteus maximus fairly well preserved, and the small intestine and colon poorly preserved. The liver, spleen, and stomach were surprisingly well preserved, better than that seen in ancient mummies. In modern cadavers, the liver is usually autolyzed by migration of intestinal bacteria via the portal vein. In the experimental mummy, that process seems to have been partially arrested, probably by evisceration of the cadaver, and many of the liver cell nuclei, the portal areas, and pathologic change, consisting of periportal fibrosis, were identifiable. The pathology seen in the liver was remarkably similar to that of an actual Egyptian mummy who died 3,200 years ago of a ruptured spleen secondary to schistosomal cirrhosis (Nakht, Chapter 6) and of modern patients with hepatic fibrosis. The general appearance was similar to that of

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other Egyptian and frozen Alaskan mummies and other experimentally mummified tissues. The preservation of the stomach was even more remarkable, in that the acidic contents produce rapid autolysis in modern cadavers. This individual had died after more than 24 hours of intravenous feeding and the stomach was empty at the time of his death. Elderly individuals often have decreased stomach acid levels as well. As a result of this study, we could now state that Egyptian mummification practices were quite effective and that there was probably little further degradation over the centuries (with the exception of mechanical disruption (i.e., tomb robbers or attack by insects). It was also possible to make presumptive diagnoses in this individual of several pathologic processes, including pulmonary edema, pulmonary thromboemboli, hepatic fibrosis, and chronic pyelonephritis, the first three being related to the death of this individual due to chronic congestive heart failure, as was documented clinically. Pathologic changes affecting these organ systems in Egyptian mummies have previously been reported and such diagnoses can now be viewed with confidence in both the efficacy of ancient Egyptian mummification practices and our diagnostic ability in examining such ancient human remains.

Chapter 9

PRACTICING MEDICINE IN ANCIENT EGYPT Let us start by imagining what Albert Einstein called a “thought experiment”. It is the year 5015 CE and an excavation of an ancient hospital, dated to ca. 2017 CE, uncovers an ancient book, written on paper rather than on the current electronic device. Although the book is in poor condition there is a partial title, M---- Man--l. The archeologist refers this 3,000 year old book to a paleopathologist who transcribes this as a Medical Manual. An inner page reveals -erck and the title is now considered to be Merck Manual. The book seems to be a compilation of disease descriptions and treatments by a long forgotten Dr. Merck. The diseases are difficult to decipher in an era when humans live to the age of 150 and die only when aged organs fail. It appears that the body could be attacked by minute parasitic organisms, visible only with an ancient tool called a microscope. Some cells appear to have taken on a life of their own, destroying the body by causing diseases know by a variety of poorly preserved terms such as cancer or neoplasm. The task of our future paleopathologist is analogous to that of the difficult undertaking of deciphering ancient Egyptian medical papyri. There are a number of surviving papyri, in various degrees of completeness, which have been studied by physicians and Egyptologists. They have done remarkably well, particularly in that the writing is mostly

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in the difficult hieratic rather than hieroglyphic text. The modern names for the papyri are either for the original buyer or the institution in which they are housed. The first question is who were the physicians? There is a distinction between the embalmers, who removed organs without any real anatomical study and the early Egyptian physicians, who developed empirical (and often magical) symptom based treatments. The one about whom we know the most is Imhotep. The chief architect to the Egyptian pharaoh Djoser (reigned ca. 2, 630 - 2,611 BCE), he was responsible for the world’s first known monumental stone building, the Step Pyramid at Sakkara. A commoner by birth, Imhotep’s intelligence and determination enabled him to rise through the ranks to become one of Djoser’s most trusted advisors. Imhotep’s influence lived on well after his death. In the New Kingdom he was venerated as the patron of scribes, personifying wisdom and education. During the Late Period his veneration extended to deification and he became a local god at Memphis where he was glorified for his skills as a physician and a healer. He is said to have extracted medicine from plants and treated diseases such as appendicitis, gout and arthritis. At Memphis he was served by his own priesthood and he was considered to be an intermediary between men and the gods. It was believed that he could help people solve difficulties in their daily lives and cure medical problems. When the Greeks conquered Egypt they recognised in him attributes of their medicine god Asclepius, and continued to build temples to him. His reputation lasted until the seventh century CE Arab invasion of Egypt. Of course, he was literally reborn twice by Hollywood as The Mummy, first by Boris Karloff in 1932 and then in a 1999 sequel. The Ebers papyrus tells us of three types of medical professionals: the doctor (swnw) a secular physician; a priest (wab) a healer; and a magician (sau). Egyptians believed that disease or pain was the effect of hostile divinities or demons and that cure could be achieved by magical or religious incantations. As effective remedies were found, a more rational approach developed. The oldest mummy of a physician was discovered recently. Qa’ar, a priest and “chief physician of the secret of the palace,” lived during the 5th Dynasty. When Herodotus visited Egypt in 450 BCE he

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noted that Egyptian medicine was that of specialists, in “diseases of the eyes, others of the head, others of the teeth, others of the stomach, and so on….” One example is a chief of dentists, Khuy, combining dentistry (ibhy) and proctology, “guardian of the anus” (neru pehut). A physician who specialized in internal medicine is known to us. Iry studied the “organs of the body that are hidden from sight”. There are records of as many as 150 snnw in pharaonic Egypt. There are also records of how physicians were paid, which appears to have been by a barter system regulated by the state. Salary was rations of cereal, bread and beer, the ingredients of a basic diet. Most physicians were in the middle class, along with priests, scribes and skilled workers, with some attached to the royal palace being elevated to the upper class. Training of physicians was by instruction within the family and by schools and apprenticeship. There was little knowledge of anatomy or physiology. The function of the brain was unknown. Thought and emotions were believed to be centred in the heart, which was not removed in the embalming process. The funerary ritual included belief that that the heart was weighed by the god Thoth against the feather of truth, maat, as noted in Chapter 1. The circulation of blood was not known and a general term, metu, probably included arteries, veins, nerves, and tendons. “Houses of life” (per ankh), perhaps a type of medical school or library, were attached to temples and teaching was somewhat harsh. An Old Kingdom maxim of Ptahhotep says, “A boy’s ears are on his back - he listens when he is hit.” Medical practice did have similarities to the present, with history, examination, laboratory studies, diagnosis, and prognosis. Thorough questioning (the history of the present illness, or HPI) was followed by examination of the body (physical examination, PE), utilizing palpation, the sense of smell and, perhaps, checking the pulse. As there was no knowledge of the circulation of the blood, it is unclear if the significance of the pulse was known. Study followed of the urine, excrement, and expectoration (laboratory results). Set phrases were used: “If you examine a man having…”; “You will say what is the matter with him; a patient who suffers from….” Treatment was based on prognosis, with three general

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statements: “A disease that I will treat”; “A disease that I will contend with”; or “A disease that nothing can be done about.” Ancillary staff appears to have been limited to massage therapy and nurses, for wet-nursing or child care. Although midwives must have existed, there is no Egyptian word for midwife and no medical papyri for childbirth. There were no pharmacists, as medications were prepared by the swnw. Medications used in ancient Egypt were aimed at symptom relief rather than cure, understandable as the cause of most diseases was unknown. Similar drugs were used well into the nineteenth century. In contrast, modern treatment is directed at cure. Magic played a major role and may have provided a placebo effect. There are many entries in the medical papyri for dietary items but these appear to have intended for therapeutic use rather than dietary correction. Little is known about how raw materials for drugs were collected. Animal products were taken from farm or domestic animals but those from wild animals, such as crocodile excrement, used as a contraceptive, must have presented certain issues. Mineral products were readily found in Egypt and drugs were prepared from a wide variety of plants. The remedies were usually introduced by the phrase, “You shall prepare (ir) for him…” followed by instructions for grinding, mashing, straining or cooking. Active principles were extracted by solution in water, alcohol or oil and administered in water, honey, milk oil, wine or beer, measured by volume rather than weight. The smallest volume was a ro, about 14 ml, or a mouthful. The most common route of administration was oral and drugs were also given by enema or suppository into the rectum. Gynecologic papyri indicate a number of remedies and suppositories to be placed in the vagina and many medications were applied directly to the skin. Fumigation, inhalation or sitting on burning medicine was also used. Although hundreds of medicinal items are in the medical papyri, many have not been translated and the diseases for which they were intended are often obscure. An example is the castor oil plant, as in several entries in the Ebers papyrus:

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a) “One crushes its roots in water, to place on the head which is sick: he will then become well immediately, like one who is not ill.” b) “A little of its fruit is chewed with beer by a man with wehicondition in his feces. This is an elimination of disease from the belly of a man.” c) “Its oil is also prepared from its fruit to anoint a man with the wehau-skin disease, affected with itjetjet and hewau, which is painful. Really excellent, a million times.” There are many remedies containing onions for snake bites. Some remedies contained as many as 37 items. It is unclear whether an item was an active principle, a vehicle or simply added for taste. Honey, for example, might work for all three categories. Many drugs, such as djaret, were used so extensively that it is not possible to determine what it was or for what it was intended. Many substances were also used for supposed magical properties. There is one instance of an effective drug that was probably administered accidentally. Tetracycline was found in the bones of a mummy from the Roman period Dakhleh Oasis site. It is possible that the antibiotic was formed in beer brewing by contamination with an airborne fungus and then ingested with the beer. Drugs of mineral origin are more easily identified. Natron (hesmen), used in mummification, was widely available and its effect in drawing out fluid and reducing swelling was used as a paste, often under a bandage. Common salt, which is a mild emetic (inducing vomiting), had a wide use. It was taken orally, by enema, or applied locally to the eyes, ears and skin. Malachite, a green pigment, was used cosmetically and for eye diseases. The green color is due to copper and would inhibit the growth of Staphylococcus aureus. The Ebers papyrus prescribes it for a burn that had become foul. Many other listed minerals are virtually insoluble in body fluids and would have had no effect. There was a wide variety of drugs of animal origin. Honey was used in hundreds of remedies, especially in open wounds, where it would inhibit bacterial growth. Milk and urine were mostly used as a vehicle. Excrement and blood was used from many species, including cat, ass, birds, lizard,

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crocodile, fly and human. Fortunately, most were applied externally, but it is hard to see any benefit. Placenta of cat was recommended to prevent hair from turning gray. Cow or goat bile was used for human bites and for eye issues. Animal fat was used in making greasy ointments and also to transfer some desired property of the animal. Meat was applied to wounds the first day, probably to aid clotting. Liver and other organs were prescribed but for untranslated disorders. There are about 160 herbal remedies that have been identified but again there is little agreement on what diseases were being treated. There is some evidence of narcotic agents but none as to their medical uses. Cannabis (hemp) was used in making rope and its medical application is occasionally seen in the papyri but without mention of an effect on the nervous system. The most effective pain medication was probably beer or wine and intoxication was well known. There were many remedies for the gastro-intestinal and urinary systems, although the distinction between the two is often unclear. The treatments generally do not define the illnesses and the large number of remedies suggests that none were efficacious. The word for cough, seryt, is well understood. There is no evidence of the use of opiate suppressants but the use of honey and dates would have provided some relief. Honey is a component of modern cough drops. The little information in the papyri on surgery in ancient Egypt indicates that it was largely related to trauma. No surgical instruments have been found. A wall relief on the temple of Kom Ombo shows a number of instruments but it is not clear if these are for surgical or simply household uses. One clear diagnosis of a case that would presently be treated surgically, an umbilical hernia, is in the Ebers Papyrus. “A swelling of … his abdomen above his umbilicus… which comes forth when he coughs…. You treat it like the sahemem treatment.” Unfortunately, the translation of that treatment is not known. Umbilical hernias are clearly depicted in some tomb reliefs. Circumcision of an adult male is shown in an Old Kingdom tomb and the hieroglyphs indicate the use of some pain medication, the nature of which is unknown. Evidence of orthopedic surgery is seen in a mummy with a prosthetic toe.

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The Edwin Smith papyrus consists of 48 cases of trauma, starting at the top of the head and proceeding down to finish with a spinal injury. The usual treatment for a wound was initial bandaging with meat, followed by oil and honey, which would lessen swelling and inhibit infection, as bacteria do not grow in honey, a hypertonic medium. That is why the honey in your kitchen is simply stored on the shelf. Stitching was recommended in appropriate cases and we have needles made of copper and silver. Infected wounds (with “ruddy lips”) were treated with herbs and green pigment, a copper salt that would have had some anti-bacterial effect. The treatment of fractures and dislocations are well described and many mummies and skeletons show good healing. One remarkable case is that of the Pharaoh Seqenenra, whose mummy shows several ax wounds incurred in battle. X-rays have shown signs of early healing on the uppermost lesion, indicating survival of at least a few months. Snake bites were much feared and the Brooklyn papyrus has an extensive listing of types of snakes, clinical effects and prognosis. Treatment was primarily local, with the addition of magical incantations. The papyrus also notes bites by scorpions (but the treatment section is lost), crocodiles and humans. We have some titles for a number of specialty practices in ancient Egypt, such as dentists and ophthalmologists but there are none for gynecology or obstetrics. It is probable that medical care of women was by women, perhaps specialized midwives. The papyri do list many tests for fertility, pregnancy and the sex determination of the unborn child. An example is moistening of seeds of barley and emmer with a woman’s urine. Growth of all would indicate pregnancy. Growth of barley would indicate a male, emmer a female and no growth would indicate that there was no pregnancy. Modern tests have shown that this test was not valid. The papyri say little about labor and delivery other than a few incantations to hasten birth. A variety of drugs are listed for contraction of the uterus. There appear to be early descriptions of complications of delivery such as fistulas between the vagina and rectum and urinary

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bladder. Information about treatment of the neonate includes prognostic indicators for survival. Various materials are recommended for contraception, all to be placed in the vagina. Some, such as crocodile excrement, might have been to discourage the male! Crocodile dung is actually slightly alkaline, like modern-day spermicides, so it could have been effective. The eye plays a major part in Egyptian mythology. The eye of Horus was torn out by Seth and magically restored, as the wedjat eye as a symbol for protection and cure. While there is no evidence of eye disease in mummies, there are many representations of blindness, particularly of harpists. Ophthalmologists were swny irty, doctor of the eyes and there are many remedies for various conditions, including blindness, cloudiness and darkness (presumably cataracts), trachoma, foreign body removal, and many words which have not been translated. Although ancient Egyptians suffered all of the dental ills seen in modern populations, including attrition, caries, abscesses and periodontal disease, and the word for dentist is ibhy, there is little in the papyri about dental operative techniques. A few remedies for strengthening the teeth are seen but the pathology is not clear and the application of herbs or honey was not likely to have been helpful. There is one example in a mummy of a dental bridge, dated to 2,000 BCE. Dentists used gold wire as a means to bind a loose tooth to a sound neighboring tooth. Patients would have their jaw bone drilled in order to drain an abscessed tooth or teeth. Carious teeth were filled using a type of mineral cement and gum disease was also treated by using myrrh and other antiseptic herbs. In conclusion, Egyptian medicine appears to have been static for over 2,000 years, from the Old Kingdom until the influence of Greek medicine. In 331 BCE Alexander established the new city of Alexandria, which became the major cultural and scientific center of the Greek world, including a medical school. Greek medicine essentially supplanted that of ancient Egypt when the Greek physician Herophilus moved to Alexandria in the third century BCE and began the modern studies of anatomy and physiology. Although the Romans ruled Egypt after 31 BCE, Greek language and medicine remained dominant. Coptic Christianity was

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established early in Egypt and medicine remained predominantly Greek until the Arab conquest of 641 CE. The language of ancient Egyptian and its medicine was lost until the nineteenth century decipherment of hieroglyphics by Champollion. We can wrap this chapter up by noting that our understanding of ancient Egyptian medicine remains an ongoing process.

Chapter 10

MY OLDEST PATIENTS While flying to Denver for a meeting of the American Association of Physical Anthropologists, the airline attendant (back in the time of the Wright brothers, they were called stewardesses) gave me a copy of the New York Times. On the science page was an article about the specimens in storage at New York’s American Museum of Natural History (AMNH), including a 25,000 year old mummified mammoth. When I got back to Philadelphia after the meeting, I sent a letter (another relic of the pre-email past) to Richard Tedford (now deceased), the curator at the AMNH, asking if he would be interested in my examining this unique specimen. His reply noted that there were several other animal mummies in the collection and I would be welcome to take small samples from them for study. Previous microscopic examination of such material had been limited to a study of bone from an Alaskan Pleistocene mammoth, showing structure comparable to modern elephants. The specimens I examined were all collected in the early 20th century by the Museum’s paleontologist Childs Frick from the area of modern Fairbanks and were recovered during gold mining operations. The remains, in the Frick Collection, Dept. of Vertebrate Paleontology, include the face and right forefoot of an immature woolly mammoth, (Mammuthus primigenius), the nearly complete remains of a rabbit, (Lepus sp.), a lynx (Lynx sp.), a lemming,

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(Dicrostonyx sp.) or vole (Microtus sp.) and marrow from a horse cannon bone, (Equus sp.). 14C dating of the mammoth indicated an age of 21,300 +/-1,300 years (Lamont Geological Observatory L-601, 1960) and the other animals probably fall within the range of 15,000 to 25,000 years based on stratigraphic evidence. The animals appeared dry and leather like, with skin and hair well preserved. Dissection of the mammoth head revealed preservation of the eyes as globoid structures filled with soft white cheesy material. The brain was not identified. The viscera of the rabbit were easily identifiable and appeared to be well preserved. The viscera of the lynx were totally autolyzed and the marrow of the horse bone was reduced to a small amount of greasy yellow material. Representative specimens of the various structures were selected for rehydration in Ruffer’s solution, overnight immersion being sufficient. Of interest was the failure of the solution to turn yellow or dark brown, a change usually seen in the rehydration of human tissues. The lemming or vole was rehydrated in toto for a week, in an effort to facilitate identification. After rehydration, the specimens were fixed in absolute alcohol and processed as would be fresh tissue. The sections were stained with hematoxylin and eosin (H&E), Masson trichrome, phosphotungstic acid hematoxylin (PTAH) and the Fontana stain for melanin. Histologic structure was found to be preserved in several of the specimens. The mammoth eye showed preservation of the extra-ocular skeletal muscles, which retained their affinity for the trichrome. The PTAH stain revealed preservation of the cross striations characteristic of skeletal muscle. Other structures and the melanin of the retina were not identified. The general architecture of the rabbit liver was preserved, the fibrous tissue of the portal areas being clearly visible. The hepatocytes had completely disintegrated, being replaced by masses of bacteria. The wall of the bowel remained as strands of tissue containing well preserved vegetable contents. No ova or parasites were seen. No trace of histologic structure was seen in the other tissues examined, including the heart and spleen of the rabbit, skin and muscle of the mammoth and lynx and the horse marrow. The

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rehydration of the lemming (or vole), was only partially successful, rehydrating only the whiskers, and did not aid in its identification. The preservative effect of freezing and subsequent mummification was thus demonstrated to last much longer than had previously been suspected. It has been suggested that most human infections originated as zoonoses and studies of ancient animal specimens might be able to identify pathogens dating back for many millennia. 40 years after this AMNH study, I am collaborating on a study of frozen seal mummies in Antarctica that may have been the vectors for transmission of tuberculosis from Africa to South America over 1,000 years ago (Chapter 21). On the other hand, a considerable degree of tissue destruction did indicate that a significant period of time had elapsed between the death of the animals and their entombment in the permafrost, countering a popular notion that Arctic mammals had been killed and preserved instantaneously by a catastrophic climate change. The rarity of complete mummies of the larger species also indicates that after death these mammal remains were usually dismembered and partially decomposed by the normal depositional processes of a periglacial environment. As I was leaving the museum, Dr. Tedford mentioned one other specimen. We clambered over a number of boxes and opened one large enough to hold a grand piano. Inside there was an entire mummified moose, in the classic position on its back with its legs straight up in the air. Thoroughly intimidated, I decided to leave that one for some future investigator.

Chapter 11

TWO MUMMIES ARE ADMITTED TO HARVARD In a 1979 study jointly sponsored by the Peabody Museum of Archeology and Ethnology of Harvard University and the Paleopathology Association, an international multidisciplinary team was assembled at the museum to examine two mummies in their collection. The first mummy, given the acronym HUM-I (for Harvard University Museum) was a young Peruvian male. Preliminary X-ray examination revealed multiple facial and skull fractures and a slightly healed trepanation. The mummy was thought to have been in storage in the museum for a century. Radiocarbon dating, performed on soft tissue from the mummy’s legs, provided an estimate of 140 ± 60 years BP. (UCLA Radiocarbon Laboratory # 2179). The mummy, therefore, may have come from the colonial period, shortly after the Spanish conquest of Peru. Trepanation is a special form of cranial trauma, the surgical removal of a piece of the skull without damaging the underlying vessels, meninges or brain. The term often used is trephination, as the instrument used is a trephine. The practice was world-wide, beginning in Europe 10,000 years ago and in Egypt, where there are only a few examples, about 1200 BCE. It is probably still practiced in Africa. In South America the practice dates to about the 5th century BCE. The procedure is done for magical or

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therapeutic reasons and it is often difficult to separate these. It may have been done for fracture or headache, or to let out “evil spirits”. In 20th century Kenya it was most often done for headache. When done postmortem, the piece of bone from the skull is used as a good luck charm. The procedure generally involved alcohol as an anesthetic and a variety of instruments to remove the pieces of bone, by drilling, scraping or cutting. The majority of patients appear to have survived the procedure. One caution is that spontaneous diseases can cause similar appearing holes in the skull. The objective of the study was to correlate disease and cause of death with available archeological information on this individual and his culture. Members of the Paleopathology Association had already participated in the examination of a number of Egyptian, American Indian, and Alaskan mummies, demonstrating the value of the multidisciplinary approach in the evaluation of paleopathologic material. The mummy (Peabody Museum # N18446) came from Llactashica in the Rimac Valley of central coastal Peru. The collector and exact date of accession were no longer known. It consisted of a flexed body, 60 cm. in overall length, naturally mummified by desiccation. On external examination of the mummy, most of the face and head was devoid of skin, revealing cranial and facial trauma, but the remainder of the body showed good preservation with only a small portion of the chest wall missing. A mummified penis was present. The frontal bone showed several lesions on the right side. Most dramatic was a beveled anterior perforation, 17 mm in outer diameter and 11 mm in inner diameter. There appeared to be some evidence of early healing, with the margins of the bone defect being slightly rounded. Lateral to this lesion was a slightly curved, depressed line 20 mm long, 2 mm wide and less than 1 mm deep, initially thought to have been an incised wound. Posterolateral to these two was an 18 x 12 x 2 mm ovoid depressed area in the outer table of the vault, the size and appearance suggesting a sling ball wound. Two sharp fracture lines in the inner table of the frontal bone radiated posteriorly from the perforation, the longer extending 40 mm to the junction with the right parietal bone. A third fracture, 20 mm long and

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unrelated to the perforation, was visible on both the external and internal surfaces. The face showed a well-healed fracture of the lateral wall of the orbit. The nasal bones were displaced 5 mm to the left of the midline and there was calcification of the nasal cartilage. There was antemortem loss of the right mandibular molars and resorption of the alveoli. The remaining teeth showed moderate attrition but were otherwise unremarkable. Radiologic examination of the skull revealed slight rounding of the margins of the perforation, providing radiographic confirmation of the gross impression of minimal healing. The fracture lines noted grossly also showed smooth margins, suggesting early healing. Slight curving of the posterior margin of the clivus was present, which may be a normal variant or due to long standing increased intracranial pressure. Other radiologic changes of note were minimal degenerative changes in the spinal column and bipartite patellae. It was estimated by radiologic criteria that this young adult man was over 25 years of age at the time of his death. The degree of dental attrition and absence of atherosclerosis suggest that he was no older than 35. The autopsy was performed by removal of the anterior thoracic and abdominal walls. Disarticulation of the legs was necessary because of a flexed position of the body. The heart, larynx, trachea, lungs, liver, gastrointestinal tract, left kidney, and pelvic organs were identified. No gross pathologic changes were seen. A considerable amount of dried grass and roots had entered the thoracic cavity through the postmortem defect. After removal of the skull cap by a circumferential incision, crumbling dried brain was seen protruding through a tear in the right superior region of the well preserved dura mater. An interesting finding was the twig of a plant with anti-bacterial properties in the skull, perhaps part of a dressing in life. There was no evidence of a subdural hematoma. The organs were removed and sampled for histologic examination. The tissues were rehydrated with Ruffer’s solution, embedded in paraffin and microscopic sections prepared. Histologic preservation was poor, with extensive contamination by bacteria, fungi, and insects. Findings were limited to the lung, which showed anthracosis, and possible silicosis and

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fibrosis. In some areas, skeletal muscle striations persisted, as did blood vessels, the fibrous stroma of the liver and spleen, and cartilage. The brain and its membranes had completely degenerated. No parasitic ova or cysts were seen in the colonic contents. The temporal bones showed no pathology. Cranial trauma has been well documented in ancient Peruvians, and the “70 caliber” depressed fractures of sling ball wounds are common findings. HUM-I was a particularly traumatized individual, whose skull showed well healed fractures of the nose, orbit and cranial vault. Several more acute linear fractures of the right frontal area were also present, and the partially healed trephination on the right frontal is probably related to this trauma. The “old incised wound” was subsequently demonstrated to be an impression of an artery in the scalp. Although trephination is thought to have been performed in antiquity for relief of headache or epilepsy or for ritual purposes, the presence of two slightly healed linear fractures in the inner table of the skull, radiating out from the trephination, suggests that this procedure may have been done in an effort to relieve the effects of a new fracture, with removal of the fracture site visible to the ancient surgeon. Since almost half of known trephined Peruvian crania exhibit trauma, this association is not unique. While more than 50% of trephined skulls are reported as showing complete healing, HUM-I did not fall into this group. The slight degree of healing of the fractures and trephination suggests that HUM-I survived for only a short time, perhaps up to a few months following surgical intervention. However, definitive criteria correlating degree of healing with survival time have not been established. Steinbock states that trephination to relieve elevated intracranial pressure was a common practice in preColumbian Peru. The level of intracranial pressure in HUM-I cannot be established with certainty, as the bony changes of intracranial hypertension may take many months to develop. The slight degree of healing of the linear skull fractures and trephination indicates a relatively acute course for this young man’s cranial injury and death.

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The twig found in the skull displayed a joint stem, indicating that it was a possible species of the genus Piper, an aromatic with antibacterial properties. Ethnobotanically, the twig might be interpreted as a posttrephination medicinal agent, perhaps used in a dressing during life, having fallen into the skull defect postmortem. HUM-I showed the marked pulmonary anthracosis seen in virtually every ancient human examined. Such findings indicate that air pollution is not unique to the 20th century. Anthracotic pigment is biologically inert carbon and organic carbonaceous compounds. The fibrosis seen in HUMI’s lungs can be attributed to exposure to silica, perhaps in the course of silver mining or processing activities. Skeletal samples from rib, tibia, vertebra, skull, and ilium were analyzed for lead by graphite-furnace atomic absorption spectroscopy. A standard reference sample of bone ash of known lead content was included in the analysis, with recoveries averaging 100%. The average lead value obtained from the skeletal samples of HUM-I was within the trace amount range, miniscule in comparison to modern individuals and similar to Egyptian mummies. The small amounts found in HUM-I may be attributed to some minimal exposure, perhaps through silver processing, lead being present in silver-containing ore. Exposed to only minimal quantities of lead, he was capable of excreting the lead and preventing significant accumulations, unlike individuals in modern populations who show much higher lead levels. No neoplastic disease was seen in this mummy, reinforcing our impression that cancer was a rare disease in antiquity. Although this was a young individual, the young of modern populations are by no means immune to cancer, being particularly liable to malignant bone tumors and leukemia. This single case can be added to previous studies and the fact remains that malignant tumors have rarely been diagnosed histologically in mummies. Short life spans in antiquity may play a role in this apparent rarity of cancer, but other diseases of the aged such as atherosclerosis and Paget’s disease of bone have been found in ancient remains. Experimental studies (Chapter 5) indicate that malignant tumors should be well preserved by mummification. Such paleopathologic studies suggest that the

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current high incidence of cancer is due to a factor or factors present in the modern industrialized world. In summary, the physical status and early demise of this individual can be related to two major health hazards of early colonial Peru, trauma and silver mining. The second mummy, a female Aleutian mummy from the Peabody Museum was named HUM-II. She had been quite literally in dead storage in the museum for over a century. As with HUM-I, the objective of the study was to correlate diseases and cause of death with available archeological information on this person and her culture. The mummy was unnumbered and labeled as: “Naturally preserved mummy from a cave in the Aleutian Islands. Presented by the Alaska Commercial Company, received through the Smithsonian Institution, 1875.” The body was in a typical flexed Aleut mummy bundle wrapped in a robe of sea otter skin, tied with leather thongs and braided whale sinew cordage. The bundle was 79 cm long. Archeological dating is to the early 18th century, too recent for accurate carbon 14 dating. X-rays confirmed the flexed position of the body. There was very slight anterior wedging of a few mid thoracic vertebral bodies, but no striking degenerative changes. The inner table of the occipital bone showed more pressure effect on the left side than the right, indicating backward protrusion of the left cerebral hemisphere, an asymmetry commonly seen in most right-handed individuals. The maxillary teeth were lost and those few remaining in the mandible showed alveolar resorption. As compared with other Aleut mummies from Kagamil Island and with US white cadavers, HUM-II presented a picture of good osteological health. The bones of the left forearm were fractured, with wide separation of the fractured ends of the radius. The pelvic inlet and sciatic notch were wide, both female characteristics. The right clavicle (collar bone) showed a 4 x 5 mm defect with smooth margins along the superior aspect, interpreted as due to either a direct blow or a partial avulsion of the insertion of some of the tendons of the adjoining sternocleidomastoid muscle.

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After the radiologic examination, the mummy bundle was unwrapped, involving disarticulation of the limbs and removal of multiple layers of the sea mammal robes. The body was seen to be that of a middle-aged woman. The fracture of the left arm noted on X-ray was determined to have occurred postmortem, the soft tissues also being transected at the fracture site. Exposure of the left humeral head showed lipping characteristic of degenerative joint disease, and similar changes were seen in the more distal joints of the left and right arms. Autopsy was conducted in what had become at that time a relatively standardized fashion for mummies, with removal of the calvarium and the anterior thoracic and abdominal walls. The only gross pathologic changes noted were adhesions of the lining of the lung to the chest wall in the region of the left upper lobe and the diaphragm, congestion of the renal medulla, and vertebral osteophytosis. The organs were found to be poorly preserved. Only the lungs, liver, intestinal tract, kidneys, and brain were identified and removed. Samples of these organs and other body tissues were selected for microscopic examination. The tissues were rehydrated and microscopic sections prepared. Microscopic examination was disappointing, revealing extensive infiltration of the tissue by fungi and by plant and insect parts. Histopathologic change was limited to the aorta, kidneys, and lungs. The aorta and an iliac artery showed calcific atherosclerosis. The kidneys were remarkably well preserved, with glomeruli, tubules, and blood vessels recognizable. The glomeruli were reduced to masses of basement membrane material, the cells having degenerated. The lining cells of the tubules were preserved in areas, and many of the tubules contained small deposits of iron and calcium, a change seen in the recovery phase of acute tubular necrosis (ATN). The larger arterioles showed minimal sclerotic changes. The lungs were very poorly preserved, with bacterial, fungal, and insect contamination, but marked anthracosis was seen. We were able to diagnose focal bronchial dilation and pulmonary and pleural fibrosis.

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A number of special studies were performed, including examination of the intestinal contents for parasites and ova, none of which were identified. Small bone cores were removed from the femoral mid shaft and subjected to photon-osteon analysis for age at death, determined to be 51 +/- 6 years. This age was consistent with age-specific changes of erosion and erratic ossification seen on the faces of the pubic symphysis. There was also scarring, evidence of having given birth, on the pubis. These findings were all consistent with the gross morphologic and the X-ray impression that this was a middle-aged woman. The temporal bones were removed and studied with an operating microscope, which permits magnification up to 40X. Examination showed excellent preservation. There was a large, kidney-shaped perforation in the tympanic membrane (ear drum) of the right ear. The margin of the perforation was smooth and well circumscribed. Two smaller, postmortem defects were seen. The ossicles were in place and there was bilateral mastoid sclerosis, more severe in the antrum. The tympanic membrane was not present on the left side. The scalp contained numerous ova of lice, Pediculus humanus capitis, attached to the hair and visible to the naked eye. After trimming the lengthy hair, several adult lice were seen as well. The lice were rehydrated in Ruffer’s solution, cleaned with an eyelash attached to an applicator stick, and examined by Pat Horne by scanning electron microscopy, showing extraordinary preservation of surface detail (see Chapter 2). These 200-year-old lice showed no essential difference from modern lice. The scalp itself showed excoriations (scratches) consistent with such an infestation. Final pathologic diagnoses were pleural adhesions, possible pneumonia or bronchiectasis, recovery phase of ATN, aortic atherosclerosis, arteriolar nephrosclerosis, bilateral chronic mastoiditis, right otitis media with perforation of the tympanic membrane, pediculosis capitis, and degenerative joint disease.

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Botanical analysis of the interior of the sea otter robe showed extensive and intricate matting over the thoracic area, consisting primarily of many different grasses of the family Gramineae, with fungi growing on these grasses, as well as moss and lichen distributed throughout the matting. The exterior of the sea lion robe showed salt crystals and the skeletal remains of minute aquatic creatures of the class Crustacea. This mummy showed the marked pulmonary anthracosis seen in virtually every ancient human examined. These findings again indicate that air pollution is not unique to the 20th century. While histologic preservation of most of the organs of HUM-II was not good, the kidneys were remarkably well preserved. The changes seen were consistent with a healing phase of ATN, probably secondary to pneumonia and pleuritis, conditions suggested by adhesions of the lungs to the chest wall. This woman also suffered from chronic otitis media and mastoiditis, but it is unlikely that these processes would by themselves have led to ATN. Meningitis secondary to mastoiditis must be considered as a possible cause of ATN, but in the pre-antibiotic era such a sequence would have been rapidly fatal, precluding the healing of ATN. HUM-II’s osteological robusticity suggests a relatively sudden death, as any chronic debilitating process might be expected to result in osteoporosis. Arthritis in unusual locations, such as the left elbow of HUM-II, is thought to be due to excessive use. As she was right handed, a speculative interpretation would be that she was holding objects firmly with her left arm and hand while doing finer work with her right hand. Remarkable also was the preservation of lice, providing clear evidence of the antiquity and ubiquity of pediculosis capitis. The atherosclerosis seen in HUM-II is a common finding in ancient bodies of the elderly. The Aleuts lived a relatively stress-free life, with food readily available from the sea and tidal pools. They ate sea mammals (whales, porpoises, sea lion, fur seals, seals, and some sea otters), fish (salmon, halibut, and cod), many invertebrates (sea urchin, mussels, limpets, whelks, and chitons), birds, and a few land and marine plants. In contrast to northern Inuit, the Aleuts ate a greater proportion of

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invertebrates. Extensive use of reefs, especially by older persons, probably contributed to their much greater life expectancy. Although mammal meat constituted a relatively small proportion of the Aleut diet, both Aleut mummies examined, this woman and the middleaged man from the Smithsonian Institution, showed atherosclerosis. Ancient Egyptians also ate little meat and their mummies show evidence of atherosclerosis disease. These paleopathologic observations raise some questions as to the associations that have been suggested among stress, diet, and atherosclerosis. No evidence of neoplastic disease was seen in this mummy, continuing our impression that cancer was a rare disease in antiquity. Although life spans were shorter in antiquity, many mummies have shown other diseases of the elderly, including atherosclerosis, Paget’s disease of bone, and degenerative joint disease, but no malignant tumors should be well preserved by mummification. These two paleopathologic studies again suggest that the currently high incidence of cancer may be due to factors present in the modern industrialized world. Skeletal samples from the tibial shaft and metaphysis and rib were analyzed for lead. The samples were dried and ashed in a muffle furnace. Lead content was measured in a graphite furnace type of atomic absorption spectrometer using both aqueous lead standards and lead additions to the sample. A standard reference sample of bone ash of known lead content was included in the analysis, with recoveries averaging 100%. No lead was detected in the bone samples from tibia and rib, using the technique described earlier. As in HUM-I, the absence of lead in this cadaver was in marked contrast to findings in modern persons. She had clearly been exposed to only minimal quantities of lead, which she was capable of excreting, unlike modern persons who show lead accumulations of up to 60 ug/g of bone ash. While generalizations based on individual studies are not without risk, the aim of continuing studies is eventual comparison of ancient and modern disease types and incidence on a population level. Examination of these two mummies from the collection of Harvard University’s Peabody Museum demonstrated the value of the application of current techniques to

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the study of specimens long in storage. Although gross and light microscopic pathologic techniques remain essential, the application of radiology (now including CT scanning), electron microscopy, neutron activation analysis, and biochemical and other special studies represents a major advance in paleopathology, allowing a whole new range of diagnostic possibilities. The availability of new techniques and the cooperation of museum directors in allowing study of their valuable specimens have coincided with the interests of a sizable group of scientists of many disciplines in providing a much needed historical perspective on the evolution of many of the diseases that afflict modern humans. Unfortunately, many of the Smithsonian mummies were skeletonized by the museum in the 1920s. HUM-II and the mummy of the middle aged male from the Smithsonian (Chapter 3) both showed evidence of pneumonia, a fatal infection in the case of the male. Other findings in common were atherosclerosis and anthracosis. Although the freezer-like conditions of the Arctic would seem to provide for excellent preservation of soft tissues, bodies are in fact preserved only under extraordinary circumstances. The frozen ground makes winter burials impossible; the bodies of those who die are put out for disposal by animals. The permafrost layer is only a few centimeters below the surface, discouraging deep burials even in summer. Cycles of freezing and thawing tend to bring summer burials to the surface, exposing remains to the ravages of climate and animals. Rare finds, such as those described above, give us a glimpse into the prehistoric Arctic and show health hazards shared by past and present inhabitants of a once remote area. These studies of Arctic mummies point out a major focus of paleopathology, the reconstruction of ancient disease patterns. Diseases such as pneumonia, anthracosis, osteoporosis, histoplasmosis and trichinosis have well known natural histories and are relatively easily explained in the context of the Arctic and Aleutian ecosystems. The lack of evidence of cancer is consistent with paleopathologic studies in other geographic areas and, as noted throughout, suggests that the factors important in the pathogenesis of this disorder are confined to the modern world.

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Figure 1. Mummies I have studied in various sites in Alaska.

Figure 2. The frozen family of Barrow archeologic site.

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Figure 3. The women of Dra Abu el-Naga fetching water.

Figure 4. The Habu Hotel (telephone #3) and the temple of Ramses III.

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Figure 5. In the tomb of Nebwenenef.

Figure 6. Mummy fragments from Nebwenenef’s tomb.

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Figure 7. The ruins of 1,800 year old Kellis in the Dakhleh Oasis: the church.

Figure 8. Opening the tombs of Kellis, Dakhleh Oasis: early morning.

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Figure 9. Mummies entombed in the Dakhleh Oasis.

Figure 10. Schistosoma hematobium ova in a mummy from the Dakhleh Oasis, far from the Nile.

Chapter 12

THE ST. LAWRENCE ISLAND INIUT MUMMY In addition to the animal mummies of Chapter 10, naturally frozen mummified bodies of ancient humans have also been found in Alaska. The oldest one, dating to about 400 CE, was that of a middle aged Inuit woman found on St. Lawrence Island. In October of 1972 a frozen body of a woman washed out of a low beach cliff at Kialegak Point on St. Lawrence Island in the Bering Sea. The Kialegak site, on the Southeast Cape of St. Lawrence Island, is about 40 miles from Russia and 130 miles from mainland Alaska. Occupation of the island can be traced back more than 2,000 years. The body was found by 3 Inuit hunters, the Gologergen brothers of the village of Savoonga. They felt that the body would be of interest to scientists and reburied it in the tundra, below the permafrost layer, which in that area is 2 to 4 inches below the surface. In the summer of 1973, visiting National Park Service (NPS) naturalist Zorro Bradley was notified of the find and taken to the burial site. With the permission of the Inuit of the island, Bradley and his colleagues exhumed the body, placed it in a plastic bag and transported it to Northeast Cape. From there it was flown to Nome and on Fairbanks, where it was stored in the freezer facilities of the federal Arctic Health Research Center (which is now a research laboratory for the University of Alaska, Fairbanks).

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Using the facilities of the research center (as arranged by Robert Rauch of the United States Public Health Service) George Smith of the NPS and University of Alaska and I performed a complete autopsy. The body was thawed at room temperature, the process taking 24 hours. Tattooing noted on the arms indicated some degree of antiquity, as this practice had been discontinued on St. Lawrence Island by the 1930s. Muscle tissue was subsequently radiocarbon dated at two separate institutions. The Smithsonian Institution Laboratory date was CE 405 +/- 70 years while the University of Pennsylvania Laboratory date was CE 370-390 +/- 90 years. This dating placed the body in the Old Bering Sea Phase on St. Lawrence Island (200-500 CE). The woman was determined to have been 53 +/- 5 years of age at the time of death, by studies of bone and teeth. Examination of the tattoos, confined to the arms, was undertaken in an effort to provide an archeological date. The arms were photographed with infrared black and white film, which has the effect of lightening the skin and darkening the tattoos. The dark blue tattooing on the right forearm, much clearer than the left, was visible on the back of the forearm, hand and fingers, starting 90 mm below the elbow. The tattoos, 10 cm in length, consisted of rows of dots with alternating lines. Tattooing on the back of the right hand was much less clear, but the infrared film disclosed a “flanged heart” design attached to a horizontal line. There were also two rows of dots on the 2nd and 3rd fingers. The tattooing on the left arm was more elaborate than that found on the right. The coloration was the same but the left arm was more desiccated than the right, making observation more difficult. The most proximal solid line had attached to it four designs that resembled the “flanged heart” as seen on the right arm, but smaller. Each of these designs was attached to the main line by a vertical line. The tattooing on the dorsal aspect of the left hand was very difficult to distinguish, even with the use of infrared photography. Piecing together the many photos taken, the design on the back of the left hand seemed to consist of an oval, which may or may not have been complete, with a line extending laterally from its proximal border. Within the oval there may have been another oval. There was also tattooing on the 2nd and 4th fingers, consisting of 2 rows of dots. The total

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length covered by the tattooing on the forearm, starting 80 mm below the elbow, was 15 cm. The process of tattooing on St. Lawrence Island was described by Otto Geist in a letter to Dr. Charles Bunnell dated 1928, as noted in Chapter 1. The artistic motifs of the tattooing correlate with artifacts and radiocarbon dates in placing this individual within the Old Bering Sea phase of Alaskan prehistory. As the body was well preserved, the autopsy was performed in a standard fashion, with Y shaped and intermastoid incisions. The internal organs were somewhat desiccated but generally comparable in appearance to those of cadavers used for anatomical dissection. The body was that of a post-menopausal woman, as atrophic internal genitalia were identified. Gross pathological changes were found in several organs. Skull fractures were seen. The heart was well preserved, with a moderate degree of coronary atherosclerosis but no evidence of myocardial infarction, acute or healed. The valves and chambers were normal. The lower lobes of both lungs showed fibrous adhesions to the chest wall and diaphragm and the lungs contained heavy deposits of anthracotic pigment. The smaller bronchi (airways) of both lungs were packed with moss (later identified at the Smithsonian Institution as Meesia triquetra), forming casts of the bronchi. A calcified carinal lymph node was found. Moderate scoliosis and aortic atherosclerosis were present. There were no gross abnormalities of the abdominal organs. The brain was a crumbling brown mass. The tissues were somewhat desiccated, a process which continues even in the frozen state. Samples were rehydrated with Ruffer’s solution, embedded in paraffin and sectioned as any fresh tissue would be. Sections of the coronary arteries showed the atheromatous deposit that had been seen grossly. The myocardium was less well preserved; striations and, as is usual in mummified tissue, nuclei were not seen. The lungs showed the patchy deposition of anthracotic pigment observed in modern patients with centrilobular emphysema. The alveolar architecture was generally preserved. Many of the alveoli appeared coalescent but this may have been postmortem change. Some moss fibers were seen in the bronchi and were associated with hemorrhage. The liver showed the distinction between the

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parenchymal cells and the portal triads, particularly with the trichrome stain. The cells contained a brown pigment that failed to stain for iron or bile and almost certainly represents lipofuscin, an aging change. The thyroid contained well preserved follicles and the colloid took the specific iron stain. The calcified carinal lymph node contained numerous concentric areas of fibrosis with central calcification. These were interpreted as healed granulomas and identical lesions were seen in the spleen and possibly the meninges (although the last were smaller and may represent phleboliths, small calcifications within veins). Examination with polarized light revealed only minute and insignificant amounts of silica and stains for tubercle bacilli were negative. Stains for fungi revealed many weakly staining budding yeast cells and hyphal filaments with the morphology of a Candida species. The same fungi were found in other tissues. Stains for Histoplasma capsulatum were negative. Microscopic fracture of the right temporal bone was seen, with associated hemorrhage indicating a true antemortem fracture. Examination of the feces revealed the ova of a roundworm, a fish trematode, Cryptocotyle lingua. The ova of this parasite have been reported in modern Eskimos but the adult worm has not been identified in humans. This finding appeared to have been due to the ingestion of the eggs of a worm that is not infectious for humans. The rarity of frozen bodies is unfortunate, as freezing appears to preserve bodies in excellent condition. Central Siberia has yielded the graves of ancient Scythians, dead for 2,000 years. These naturally refrigerated graves contain a wide assortment of grave goods and well preserved human bodies of tribal chiefs, which had been eviscerated and embalmed. Since the organs were not found in the graves, autopsy was not possible. An autopsy of a frozen Inca child revealed infestation by the whipworm, Trichuris trichiura. A partial autopsy was performed on the moderately well preserved body of Charles Francis Hall, a 19th century Arctic explorer, who was found to have suffered arsenic poisoning, presumable caused by other members of his expedition. I later had the

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opportunity to examine a number of frozen bodies from Alaska (Chapters 13 and 14). The finding of this well preserved Inuit body afforded us a unique opportunity to perform a complete autopsy. Our conclusion was that this middle aged woman had been trapped in her semi-subterranean house by a landslide or earthquake and had been buried alive and asphyxiated. This conclusion was based on several facts. The body was unclothed and Eskimos are unclothed only in their houses; when burial is deliberate, they are clothed. In view of the preservation of the body, one would have expected any clothing to have been preserved as well. Aspiration of foreign material into the bronchi is known to occur in accidental inhumation and has been demonstrated in persons who fall into or are buried in coal heaps. The microscopic finding of hemorrhage associated with the moss fibers in the bronchi is consistent with asphyxiation. It is not unusual for red blood cells to be preserved for extended periods. Preserved erythrocytes have been reported in the tissues of Peruvian and North American Indian mummies and in 5,000 year old Egyptian mummies. The fracture of the right temporal bone confirmed the role of trauma in this unfortunate woman’s death. Far removed from the stresses of modern technological society, this woman suffered from coronary artery disease, a process that has been well documented as far back as dynastic Egypt by both historical and anatomical evidence. The present case not only confirms the antiquity of coronary atherosclerosis but also its occurrence in a preliterate society. The finding of severe anthracosis can be attributed to a lifetime spent around open cooking and heating fires. Similar findings have been reported in many mummies and demonstrate that air pollution, at least on a local level, is not a recent phenomenon. Several of the organs also showed a healed granulomatous process. Tuberculosis is considered to have been nonexistent in Alaska prior to its introduction by the Russians in the early 18th century. Of the fungi pathogenic for man, only H. capsulatum is thought to occur in Alaska, although less than 1% of modern Inuits show a positive skin test for this fungal infection. Although H. capsulatum was not demonstrated in the

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tissues the distribution of the granulomas was most consistent with the diagnosis of healed histoplasmosis. The Candida sp. found in the granulomas and elsewhere in the body was undoubtedly a postmortem invader. The weak staining of the fungi indicates contamination some considerable time in the past, perhaps shortly after death. In summary, this middle aged woman was thought to have suffered a traumatic death some 1,600 years ago. There was gross and microscopic evidence of skull fractures and the finding of aspirated moss associated with hemorrhage suggested that accidental burial and suffocation played a significant role in her death. Other pathologic changes included coronary atherosclerosis, scoliosis, pulmonary adhesions, anthracosis and emphysema and probable healed histoplasmosis.

Chapter 13

THE FROZEN FAMILY OF BARROW, ALASKA Several frozen bodies, radiocarbon dated to ca. 1,500 CE, were recovered from a site in Barrow, the northernmost point of Alaska. This story begins when I was in a conference several years ago and my secretary came in and stage whispered in my ear that I had a long distance call from Alaska. I realized immediately what the call had to be about and as I walked down the hall to my office I began thinking how I could rearrange my August vacation and examine the frozen body that I was sure had been found. It turned out that my guess was only partially complete. Dr. Wayne Myers, at that time Dean of the WWAMI program, a collaborative medical school among universities in five northwestern states, Washington, Wyoming, Alaska, Montana, and Idaho and the University of Washington School of Medicine, told me that an archeological team for the State University of New York at Binghampton had uncovered the remains of five or more Inuits in a crushed winter house on a bluff overlooking the Arctic Ocean. Dr. Myers asked if I could come to Fairbanks, Alaska, where the bodies would be brought for examination. After quickly agreeing, my next move was to call my wife, who takes notes and photographs in these studies. I asked her if she would mind if we went hiking at a different mountain in August - instead of the Sierra Nevada, Denali (Mt. McKinley).

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Her response was, “Do I have 24 hours?” Actually, we had about 2 weeks and were able to sandwich in a quick trip to Glacier Bay National Park before flying to Fairbanks and shattering the usual routine at the Fairbanks Memorial Hospital. My colleague Dr. Arthur Aufderheide agreed to join me in examining this unique discovery. At that point I was able to learn the details of the discovery. The site, in Barrow, the northernmost community in Alaska, was thought be several hundred years old. The town of Barrow was using some of their new-found oil wealth to install flush toilets, at a staggering cost (but probably less staggering than the aroma of springtime Barrow in the pre-flush days). The project involves placing a central apparatus called a Utildor in the permafrost. The archeologist team had been doing salvage archeology at nearby Prudhoe Bay related to the oil discovery there and thus was on the spot when one of the Barrow natives found a foot sticking out of the ground just west of the town, in the ancient village site of Utqiagvik. He notified the local police officer, who realized the antiquity of the find and asked the archeologists to excavate the site. They found a Pompeii-like situation, as an entire family had been trapped in their house on a bluff overlooking the Arctic Ocean. Spring storms can break up the ice and force it onto the shore with tremendous destructive force, a process known in the native Inupiat’s language as ivu. The crushing of houses in the area of Barrow and Utqiagvik is well known. As we subsequently determined, this family was trapped while asleep, crushed and frozen in their house. Dr. Aufderheide and I were confronted with a frozen mass of sleeping robes, bodies and bones. The first step in this type of study is thawing out of the remains, which takes about 24 hours at room temperature, followed by X-rays. We were fortunate in that CT scans were available, allowing us to sort the remains into 5 individuals. Three of the bodies, a 20 year old female, a 13 year old male, and an 8 year old female, had been reduced to skeletons. The other two bodies were intact and extraordinarily well preserved. Based on where they were found in the house, the intact bodies were named the Northern Body (NB) and Southern Body (SB), while the 3 skeletons, found on the floor, were simply labeled as skeletons 1, 2, and 3. The three skeletons were quite a jumble and while we were able to sort

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them out for aging, they showed no pathologic change other than a general disarticulation and mixing, so we concentrated on the two intact bodies. Our initial thought was that the site dated to about 1,800 CE but a radiocarbon date on the femur of the NB was found to be 1,520 CE, +/- 70, well before European contact in the area (and in most of the New World). The NB was an adult female, about 25 to 30 years old. She was found on the sleeping platform in the back of the house, wrapped in her sleeping robes but otherwise unclothed. When the body was thawed out, she was found to be very well preserved, with the skin still soft and pliable. The body was essentially complete, missing only the forearms and hands and weighing about 40 pounds. An eiderdown blanket was removed, revealing the right hand, which had been severed at the wrist. The entire right hemithorax was crushed, with multiple rib fractures extending in a line 3 cm lateral to the sternum. With this degree of preservation, a relatively standard autopsy was possible, including the standard Y shaped incision. We chose to remove the organs one at a time, the Virchow technique, as is generally done in examining mummies. The right pleural cavity contained approximately 250 cc of frozen clear yellow fluid. The right lung was completely collapsed, lying next to the spinal column, while the left lung was still partially inflated. The other remarkable finding was that the lungs and hilar lymph nodes were pitch black. Houses in Utqiagvik were semisubterranean and entered through a tunnel below the floor of the house, entry to the house being through a hole in the floor. The houses were heated with small seal oil lamps, which made it warm enough that the Inuit could be unclothed in their houses. The tunnel acts as a cold trap, since the hot air will not sink into the tunnel when the door is opened. This arrangement, however, traps smoke in the house and the effects of breathing this atmosphere are clearly seen in the black lungs and hilar lymph nodes. It was the duty of the women to trim the lamp at night and sleeping next to the lamp increased their exposure to smoke and resulted in severe anthracosis at an early age. Although anthracotic (carbon) pigment is relatively innocuous, with the introduction of cigarette smoking to

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Alaska during World War II a synergistic effect has developed and lung cancer is a major health concern for modern Inuit women. This young woman’s heart showed a slight dilatation of the right side, probably related to obstructed pulmonary blood flow through the crushed and collapsed lungs. Her coronary arteries were free of disease. The abdominal viscera were easily identified and appeared to be well preserved. Microscopy of the liver and gall bladder revealed normal architecture. Examination of the intestines was somewhat disappointing as there was considerable loss of cellular detail and fungal contamination. The bones were markedly osteoporotic, easily sliced with a scalpel. The urinary bladder was markedly dilated and the stomach empty. Similar findings in the other body led to the conclusion that the catastrophe occurred early in the morning, trapping the sleeping family. The other adult, the SB, did try to escape. Her body was found in the doorway, with her boots in one hand, a fish shaped dish or tray, apparently part of her sewing kit, in the other and a blanket in her arms. She was found with a roof beam across her chest and there were multiple fractures of both right and left ribs. The CT scan had seemed to indicate that the lungs were inflated but it turned out that she had bilateral frozen pleural effusions with many bubbles in the ice. The body was so well preserved that I was able to use the Rokitansky autopsy technique, removing the organs in one block. This approach allows for detailed examination of the organs and their interconnections and as far as I knew had not been used in any other mummy. The SB was aged at 42-45 years, so she had more time to acquire evidence of disease. The lungs and lymph nodes were even more severely anthracotic. She had atherosclerosis, involving the aorta and a coronary artery. The mitral valves showed focal calcification, for which the differential diagnosis includes rheumatic valvulitis, unlikely as there was no shortening or fusion of the chordae tendinae, and calcific mitral stenosis, again unlikely as the calcification was out on a leaflet rather than in the ring, and she was too young for this disease. The most likely choice was a healed bacterial endocarditis, even considering the odds against survival in the pre-antibiotic era. Two other points supported this

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diagnosis. Pleural adhesions suggested a previous bout of pneumonia, as a source for bacteremia, and the kidneys showed changes of healed tubular necrosis (ATN), focal concretions that stained positively for iron and calcium, indicating that she had survived a serious illness earlier in life. Her breasts were prominent on gross examination, much more so than the other female mummies I have examined, and histologic examination showed the hyperplastic lobules of lactation. Although the vessels in the uterus showed the calcifications we see appearing in modern perimenopausal women, it would appear the SB was still reproductively active. A corpus luteum was found in one of the ovaries, indicating delivery within 6 months prior to death. A baby was not found and may have been completely destroyed, or was not in the house at the time of the catastrophe (either being elsewhere or having died previously), or perhaps it survived. Examination of the diaphragm revealed several ovoid structures highly suggestive of trichinosis. This disease is fairly common among the Inuit, who eat polar bear meat and rarely cook it thoroughly, as fire wood is scarce in the Arctic. A healed granuloma was seen in the lung, probably due to histoplasmosis. Stains for microorganisms and antigen studies by the Centers for Disease Control in Atlanta were negative, so the diagnosis is based on the microscopic size and the absence of tuberculosis before European contact. The St. Lawrence Island mummy showed similar lesions (Chapter 12) but this sample is too small to state that the disease was common in ancient Alaska. The fungus Histoplasma capsulatum today has a worldwide distribution and is seen occasionally in native Alaskans. Both the NB and SB showed severe osteoporosis, the bone spicules being remarkably thinned and decalcified. Osteoporosis is a major health problem for modern Inuit and the gaining of a historical perspective on this disorder was one of the reasons the village elders in Barrow allowed us to do this study. Knowing now that this disorder is of some antiquity, we are at least relieved of the responsibility of a modernized western diet as a causative factor. The long, dark Arctic winter has been suggested as a factor, but the resultant Vitamin D deficiency would result in osteomalacia (softening of bone), with broad bands of uncalcified osteoid, rather than

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the thin spicules seen in these osteoporotic bones. The most likely cause is the traditional high protein diet, resulting in a metabolic acidosis and consequent calcium loss from the bones. A number of special studies, done by other investigators, can only briefly be summarized. No parasites were found in the fecal material and there was absolutely no lead in the bodies. Aging was done by examination of bones and teeth with good agreement by several different methods. The bodies were reburied in accordance with the wishes of the elders and the artefacts and records of the studies have formed a modest museum display in the town hall in Barrow, as a memorial to this family and to the human ability to survive in hostile environments. Another group of frozen Inuit bodies was found in Greenland in 1972, near the abandoned settlement of Qilakitsoq. Their tattoos are described in Chapter 1. This unique find, radiocarbon dated to the 15th century CE, consisted of eight fully clothed bodies, preserved by low temperature and humidity in two adjacent sheltered grave sites that was part of an organized settlement. The mummies, who were living at the same time as the last descendants of Erik the Red in Greenland, were representative of the Skrellings described in Icelandic and Norwegian Sagas. The bodies were studied in Copenhagen by Dr. J.P. Hart Hansen and his colleagues and then returned to Greenland, where four of them are displayed in the Greenland Museum. The other four bodies were subjected to full dissection, and in only one, a 20 year old woman, were internal organs identified. The only pathologic diagnosis was anthracosis. Radiological examination of a child’s mummy showed Down’s syndrome, necrosis of the femur, and osteoporosis consistent with a severely disabled condition. A woman in her 50s showed destruction of the base of the skull, consistent with nasopharyngeal carcinoma, a relatively common disease among the Inuit of Greenland and her probable cause of death. A wide range of studies was performed on the mummies, including studies of teeth, eyes, skin, intestinal contents, skeletons, trace metals, fungi, bone mineral, etc. The results were a fine example of the value of the interdisciplinary approach to such rare finds.

Chapter 14

AGNIAYAAQ: A PREHISTORIC ESKIMO CHILD IN ALASKA In 1994 an archeologic team found the frozen body of a little girl at Ukkuqsi in the old whaling village of Utqiagvik, near Barrow, Alaska. The archaeological context and radiocarbon dates indicated that she was a member of the semi-nomadic Thule culture, ca. CE 800-1,200. She had been buried in a meat cellar dug partly through an abandoned house floor. In August of that year I received a call from Anne Jensen, an Alaskan archeologist, asking me to examine the body of the child. The body was brought to Providence Hospital in Anchorage. As I was the Director of the Center for Clinical Laboratories, The Mount Sinai Medical Center at that time, I flew to Anchorage on a Friday, examined the body on Saturday, August 20 and flew back to New York on Sunday. The 6 kilogram body was that of a female Eskimo child appearing approximately 5 or 6 years old, named Agniayaaq (Little Lost Child) by the children in Barrow. The skin was dark brown, somewhat soft and flexible, except for the face, which was yellow and partially dried out. The nose was somewhat collapsed. The body was partially encased in an extremely wet but essentially intact bird skin parka with the feathers on the inside. A fur ruff surrounded a hood with several small points, which was indicative of the female sex. The body was in a “knee-chest” position with

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the arms drawn up to the chest inside the parka. Full juvenile dentition showed a moderate amount of wear, the teeth being worn evenly across the opposing surfaces. X-rays showed a number of growth arrest lines in the distal tibia and confirmed an approximate age of 5-6 years. No fractures or other evidence of trauma was seen. Several small (0.5 cm and less) ovoid opaque bodies were noted in the lower abdominal cavity. The chest and abdomen were intact and there was no gross evidence of trauma. The chest was somewhat distorted, with the right side of the chest protruding forward. The body was opened through a standard autopsy incision, revealing watery blood tinged fluid in the chest and abdominal cavities. The thoracic and abdominal organs were intact and sampled for microscopic examination. The stomach contained a small amount of granular, sand-like material with apparent fragments of hair. The large intestine was noted to be full of pebbles, fragments of gravel and fecal material, with masses of large deeply pigmented hair shafts that appear to be of animal origin. No parasites were seen. The bones were markedly osteoporotic and easily cut with a scalpel blade. On microscopy, the bone spicules were very thin with minimal calcification, a pattern of osteoporosis similar to that we have seen in other ancient Eskimo bodies and attributed to a meat based diet. The rest of the organs, including the kidneys and spleen, were fairly well preserved and showed nothing of note on gross examination. The heart was extremely well preserved and showed no pathologic change. The lungs, however, were black, due to the deposition of anthracotic pigment from smoke in the dwelling place. A one cm air filled bleb was seen in the upper portion of the right lower lobe. The left lung was more flattened than the right and was not as well aerated. Anthracotic lymph nodes were identified in the hilum of both lungs. Microscopic examination confirmed a marked degree of anthracosis and the usual alveolar architecture was distorted by marked coalescence and interstitial fibrosis, particularly evident on trichrome staining. A PAS stain did not reveal an excess of mucin production in the bronchi, ruling out cystic

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fibrosis. Within many of the smaller alveoli edema fluid was noted. There were no inflammatory infiltrates in the lung tissue or on the pleural surface. The hilar lymph nodes showed anthracosis but poor preservation of nodal structure. The chest fluid contained numerous bacteria and fungi, as well as amorphous basophilic material, probably representing degenerated and unidentifiable cells. A chemical test on the fluid for blood pigment was positive. At the time of autopsy, I thought she might have died of pneumonia, based on the fluid in the chest, but this fluid appears to have accumulated because of hypoproteinemia in a state of starvation. The medically interesting part of this study is that she had extensive damage to her lungs, with scarring and coalescence of the airspaces. Pulmonary anthracosis, the accumulation of carbon pigment secondary to exposure to open heating and cooking fires, is a common finding in ancient bodies, but the degree of destruction of the lung seen in this case is exceptional. This disorder, emphysema, is commonly seen in elderly cigarette smokers, in whom it causes respiratory difficulty. Because the airspaces are enlarged, the air in the center of the spaces is too far away from the blood vessels in the lung for oxygen exchange to take place and these patients don’t have enough oxygen in their blood. The disorder, rare in children, is seen in this case as a complication of a rare genetic disorder, alpha-l-antitrypsin (AlAT) deficiency. The sequence in this disease is that the affected individual has a lung infection and inflammatory cells go from the blood into the lungs. In an attempt to destroy the invading bacteria, the cells release destructive enzymes. To prevent destruction of the lung itself, there are other enzymes in the body that counteract the destructive enzymes. Patients who have an inherited deficiency of serum AlAT are unable to inactivate these destructive enzymes in their lungs. Unchecked activity of one particular enzyme, elastase, leads to destruction of elastic tissue in the walls of the lung alveoli, leading eventually to continued stretching of the airspaces and pulmonary emphysema. Elastase has been shown to induce emphysema when put into the lungs of experimental animals. The gene for AlAT has been identified in a specific site on chromosome 14. Roughly 2 in 10,000 of the United States population

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suffer from this disorder. The disorder is 7 times more frequent in Scandinavians, which raises the possibility that this may represent a circumpolar disorder. The next question that arose is how does one make this specific diagnosis of AlAT deficiency? AlAT is a glycoprotein synthesized in liver cells. When a mutant gene is present, the protein differs from the normal by a single amino acid substitution and is not secreted by the hepatocytes (liver cells). The abnormal AlAT accumulates within its cells of origin rather than being released into the serum. It creates round-to-oval cytoplasmic globular inclusions in hepatocytes, which in routine H&E stains are acidophilic and indistinctly demarcated from the surrounding cytoplasm. They stain strongly positive with the special stain PAS, which also stains sugars. However, sugars do not stain when the tissue is exposed to an enzyme called diastase, which splits the sugars. The inclusions of AlAT deficiency are diastase resistant. The liver in the Eskimo child was well preserved and showed no gross pathology. However, microscopic examination of the liver showed extensive scarring, best seen with a trichrome stain. The PAS stain showed PAS positive, diastase resistant material within the better preserved hepatocytes. Immunohistochemistry for A1AT was positive, although in a focal pattern somewhat different from the diffuse pattern seen in modern cases. This overall microscopic examination was however diagnostic of AlAT deficiency. In modern patients, these inclusions are scattered throughout the cytoplasm and do not displace the nucleus, but when numerous, they may coalesce into a single, large globule pushing the nucleus to one side. Electron microscopy, which provides much higher magnification, shows that the bodies lie within subcellular areas called smooth and rough endoplasmic reticulum. There was poor preservation of the ultrastructure of the liver but amorphous material was present that appeared to be the abnormal AlAT.

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Clinical liver disease is also associated with this abnormality, ranging from neonatal hepatitis to childhood cirrhosis to cirrhosis that becomes apparent only late in life. Rarely, liver cancer complicates the liver disease in adults. The clinical course of AIAT deficiency is variable. The disease may present with respiratory disease due to emphysema or it may become apparent as liver disease at any time from birth to adulthood. At birth or a few months later it may be discovered because of laboratory evidence of abnormal liver function or overt hepatitis with cholestatic jaundice. Later in adolescence it may take the forms of hepatitis or cirrhosis but in other instances it remains silent until cirrhosis appears in middle to later life. Attacks of hepatitis may subside with apparent complete recovery, or they may become chronic and lead progressively to cirrhosis. The role of the accumulation of AIAT in the induction of the liver disease is not entirely clear. Some patients have no detectable AIAT in the blood or characteristic globules within hepatocytes and have no evidence of liver disease. Although this would suggest that the accumulation within hepatocytes is damaging, numerous inclusions may be present in completely viable cells, arguing against direct cytotoxicity. Moreover, globules may not be evident in individuals with a deficiency state and welldeveloped hepatic disease. Much remains to be learned. Isotopic analysis on her hair, by Roy Crouse, Ph.D., Department of Physics, University of Calgary, Alberta, Canada, indicated that her diet was derived from marine food resources, similar to those of other ancient marine populations. This approximately 6 year old girl appears to have died of starvation about 1,000 years ago. Her lower intestine was filled with gravel, sand, pebbles and animal hair, indicated that normal food sources were unavailable. Older Inuits in Barrow related that when food was scarce children were given animal furs to chew on. The terminal event was pulmonary edema, probably secondary to hypoproteinemia, with the accumulation of bloody fluid in the chest cavities and collapse of the left lung. A severe degree of emphysema, secondary to a rare congenital disorder, alpha-1-antitrypsin deficiency, was a contributing cause to her death. This disease accounts for the multiple bouts of illness she undoubtedly suffered during her brief life, as evidenced by numerous

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growth arrest lines (“Harris lines”) observed by X-ray in her long bones. Her state of chronic illness is probably related to her deliberate burial, a rare finding in ancient Inuit populations. It is clear that this chronically ill child, Agniayaaq (Little Lost Child), was kept alive and treated with loving care in life and in death.

Chapter 15

PALEOPATHOLOGY AND HUMAN EVOLUTION Some of my research in paleopathology has involved the study of skeletal remains and two particular examples relate to human evolution. I was contacted regarding the possible diagnosis of unusual skeletal lesions in an ancient human fossil, a Homo erectus skeleton. The skeleton was found in the East Rudolf area of Kenya in 1973 by a team headed by Richard Leakey and Kamoya Kimeu of the Kenya National Museum and Alan Walker of Johns Hopkins University. The area was sieved and the most complete Homo erectus skeleton known was recovered, albeit rather fragmentary. The fossilized skeleton was labeled Kenya National Museum1808 (KNMER-1808). After 50,000 fragments were assembled, the shafts of most of the long bones were seen to show diffuse superficial deposition of bone. The skull was uninvolved. Histologic examination, done by grinding the fossilized bone into thin sections, revealed the deposits to consist of dense cancellous type bone sharply demarcated from the overlying cortex, with a striking enlargement of the osteocytic lacunae. The specimens remain in Africa, but I was given photographs and photomicrographs in consultation and came to a diagnosis of hypervitaminosis A.

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Vitamins are divided into the fat soluble vitamins, A, D, E and K and the water soluble vitamins, the B vitamins and C. Deficiency or overdosage of several of these vitamins affect the skeleton and are therefore of paleopathologic significance. Vitamin A (Retinol) functions in maintaining vision in reduced light and in the differentiation of specialized epithelial cells, primarily those which produce mucus. Natural sources are eggs, butter, milk, fish liver and carotenes in green and yellow plants. Deficiency is a worldwide problem, resulting in xerophthalmia (keratinization of the conjunctiva), keratomalacia (corneal softening and ulceration), corneal scarring and blindness, and impaired immunity leading to excess infectious mortality in children. There is also some epidemiologic evidence of increased cancer of the skin and lungs. Clinical symptoms include night blindness due to failure of formation of rhodopsin in the retina. Multiple skin nodules are formed by plugged follicles, and squamous metaplasia of the respiratory system predisposes to pneumonia by interfering with normal mucociliary mechanisms. Therapy, as with the other deficiency diseases, consists of replacement and care of the complications of the disease. A variety of skin diseases also respond to retinoid therapy. Vitamin A can also be ingested in excess. This disorder is essentially a phenomenon of western society, usually in situations of non-medically supervised self-medication or misguided overenthusiasm for vitamins by the parents of infants. Acute toxicity produces headache, vomiting, stupor and papilledema, symptoms suggestive of a brain tumor. Discontinuation of intake relieves the symptoms. Carnivore liver is very high in vitamin A and early arctic explorers developed these symptoms shortly after the ingestion of seal, polar bear or dog liver. The Inuit are aware of this effect and will not eat polar bear liver. Chronic toxicity causes anorexia, nausea and vomiting, dry skin, hepatomegaly, periosteal bone deposition and visual and mental disturbances. KNMER-1808 is an example of a case of a young woman who probably complained of all of these symptoms. The catch is that this is the skeleton of a prehuman fossil over a million and a half years old that shows classic lesions of hypervitaminosis A. We need to start with a brief review

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of human evolution. Since the 1920s it has been held that human evolution followed a straight line that was characterized, in a necessary oversimplification, as Australopithecus africanus, about 1-2 million years BP (before present), to Homo erectus, 0.5 million years BP, to Homo sapiens neanderthalensis, 1-200,000 years BP to Homo sapiens sapiens, about 50-100,000 years BP. However, new finds and better dating have changed our concepts, although there is still considerable controversy in the field. My understanding is that Homo habilis, discovered in Kenya by the Leakeys, is a more “modern” form antedating the australopithecines, who are now regulated to the sidelines. Homo erectus succeeded H. habilis, probably about 5 million years ago and, starting in Africa, expanded into Europe and Asia. Sometime around 500,000 years ago, Homo sapiens evolved with two subspecies, the Neanderthals and modern humans. Neanderthals are thought to have been a subspecies hyperadapted to the periglacial environment of the Ice Age and to have died out about 30,000 years ago. The H. erectus fossil I studied was dated by K/Ar dating of the surrounding rock. This technique is based on the degradation of potassium to argon, a time related phenomenon independent of temperature variations. The overlying rock, referred to as the Koobi Fora Tuff, has been dated to 1.56 million years BP, and the underlying Olduvai event to 1.76 million years BP. A reasonable estimate of the age of the fossil is thus about 1.6 million years BP. KNMER-1808 showed a broad sciatic notch, a female trait. The 1808 skeleton is one of the few for which we have post-cranial remains. Oddly, the first H. erectus fossil, found in Java by Dubois in the early 20th century, was also postcranial and also pathologic, with a projecting deposit on the femur variously interpreted as fluorosis or myositis ossificans. All of the 1808 long bones show pathologic changes. The clavicle and fibula, radius and ulna show a diffuse deposition of new bone along the diaphyses (shafts). Casts were made of the underlying bone by sectioning the specimens, identifying the underlying normal bone. Tibial casts show the same thick deposit of new bone.

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Thin ground sections were prepared and a cross section of the femur showed the thickness of the deposit. The deposits, up to 7 mm thick in areas, consist of coarse new subperiosteal bone sharply demarcated from the underlying normal cortex. A striking feature is enlargement of the osteocytic lacunae. Because of the dense fossilization, X-ray analysis could not be done. It is generally true that a disease that no longer exists, or that manifests itself today in a different way, cannot be diagnosed. With that caveat in mind, the most likely diagnosis is hypervitaminosis A. While the effects of Vitamin A deficiency have been known since antiquity, hypervitaminosis A was not recognized until the mid-nineteenth century, when polar explorers reported the development of an acute toxic state upon ingestion of polar bear, seal or husky dog liver. Vitamin A was not identified as the toxic agent until 1942. The acute disease is characterized by peeling skin, vomiting and diarrhea, weakness, headache and convulsions, while the symptoms and signs of chronic disease are more subtle. It is fairly common in children but only a few cases have been identified in adults, mostly food faddists. These individuals have shown changes very similar to those seen in KNMER-1808 and these bone changes have been reproduced in experimental animals. There are other conditions that cause extraosseous calcification, including hypervitaminosis D, hyper- and hypoparathyoidism and fluorosis, but these conditions can be excluded for various reasons. The most likely source in our fossil for the vitamin is carnivore liver, as the ingestion of 400 grams a day would be enough to cause the disease. This was a time before the use of fire, the earliest evidence for which is about one million years ago. The liver may well have been a preferential food, as it is easily chewed when raw (indeed, this is the trap the polar explorers fell into when they ran out of matches or firewood). This early period of human dietary experimentation was not without its hazards. An alternative source is excess ingestion of bee brood, a combination of wax and honey, which still is used as a food source in Africa. The other ancient skeletons I studied were of Neanderthals. Thanks to a fellow Penn graduate student, Erik Trinkaus, now the Mary Tileston

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Hemenway Professor of Physical Anthropology at Washington University in St. Louis and one of the world’s experts in the study of Neanderthals biology and human evolution, I had an opportunity to study a number of Neanderthal skeletons showing trauma. Trauma appears to have been common throughout human evolution and before humans as well, with fractures being seen in dinosaur skeletons. Fractures are common among non-human primates as well, with many wild gibbons showing healed fractures. The remains, in the Iraq Museum in Baghdad, are originally from Shanidar cave, studied by Professor Ralph Solecki from 1951 to 1960. The cave is isolated in the Zagros Mountains of northeastern Iraq. The excavations yielded the partial skeletons of nine Neanderthals. Published descriptions of the Shanidar Neanderthals have made frequent reference to traumatic lesions in the remains. In fact, four of the six reasonably complete adult partial skeletons exhibit some form of trauma related abnormality and at least two of the individuals appear to have been severely debilitated by their injuries. Evaluation of these lesions does require some precautionary statements. The analysis of trauma among the Neanderthals has been limited by the paucity of well-preserved remains. Accurate diagnoses of individual lesions are usually possible, but the incomplete nature of most of the skeletons limits assessment of the individuals’ overall health status. Population profiles for the incidence of specific injuries are impossible, as the fossils are too few and too fragmentary. With their great spatial and temporal distribution, meaningful statistics cannot be provided. As a result, previous studies of trauma among the Neanderthals have been concerned largely with the description of abnormalities, either in reference to a specific fossil or as part of a review of Neanderthal pathology in general. Although limited in scope, these studies do provide data that may suggest patterns of injury among Neanderthals. The Shanidar Neanderthals consist of the partial skeletons of 7 adults (#’s 1-6 and 8) and 2 infants (Shanidar 7 and 9). The remains vary from a largely complete skeleton (Shanidar 1) to a few fragmentary postcranial bones (Shanidar 8 and 9). Of the adults, 6 (Shanidar 1-6) appear to be

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sufficiently complete to have preserved evidence of major traumatic injury if such existed. All except Shanidar 1 lack at least one limb, a major portion of the axial skeleton or much of the skull, so we are limited to considering only positive evidence of trauma. Negative evidence is simply inconclusive, given the general state of the Shanidar Neanderthals (and all other Pleistocene hominid remains). As in the forensic science world, the absence of evidence is not evidence of absence. The Shanidar Neanderthals derive from the upper half of the Mousterian levels, Layer D, of Shanidar Cave, distributed through 3.5 meters of deposits. On the basis of sedimentilogical, palynological, faunal and radiometric analyses, the fossils have been dated to the first half of the last glacial period in this area. Shanidar 1 comes from the top of layer D and has been dated to 47-50,000 years BP. The others are older, ca. 60,000 years BP. It is clear that these fossils span a considerable geologic time and cannot be regarded as part of a single population but they do form a morphologically homogeneous geographic sample from the same time period as most Neanderthals. The diagnosis of an injury in a fossil hominid can best be made if the trauma occurred sometime before death. Some evidence of healing, usually in the form of bony deposition, must be present to make a positive diagnosis of antemortem injury. Given the tendency of fossils to fragment in situ, it is often not possible to distinguish a fatal wound from taphonomic changes, i.e postmortem psuedopathology due to breakage, animal gnawing, or even excavators’ shovels. It is also possible to infer trauma from the presence of highly asymmetrical osteoarthritis, particularly in the lower limb, where normal biomechanical stress and age related rates of degeneration should be relatively symmetrical. A variety of other changes may be associated with trauma but any connection should be evaluated on an individualized basis. Shanidar 1 was an adult male and one of the most severely debilitated Pleistocene hominids. He had suffered multiple fractures, involving the cranium, right humerus and right fifth metatarsal. He had osteoarthritis of the right knee, ankle and first tarso-metatarsal joint. The exact interrelationship of the lesions is quite complex.

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The preserved bones of the right arm, the clavicle, scapula and humerus, are clearly abnormal. They are much smaller than the corresponding bones of the normal left arm. The clavicle (collar bone) is reduced by 15%, the scapula (shoulder blade) by 35% and the humeral shaft by 45%. The preserved portion of the right humeral shaft, which extends from the surgical neck to near the elbow, at the mid-olecranon fossa, measures 243 cm, which is 10% reduced as compared to the left. The scapula shows no abnormalities other than a general reduction in size. The clavicle and humerus show other abnormalities. The right clavicle shows evidence of infection, an opening of an osteomyelitic lesion (a sinus) surrounded by a callus of subperiosteal bone. X-rays show a thinning of the bone’s walls, probably as a result of pressure from the infection within the medullary cavity. The infection was probably produced by a soft tissue injury adjacent to the clavicle. The right humerus shows three fractures, in addition to its reduction in size. Two of the fractures occurred about 2/3rds of the way distally along the shaft. Although both reunited and healed, they produced a permanent deformity in the distal humerus. Callus formation and resorption of cortical bone in the area of the fractures resulted in a sinuous shape and angular deformity to the bone. The third fracture was complete and transverse at the distal end of the humerus, with an irregular edge, flattened anteroposteriorly, with much trabecular bone exposed and the elbow missing. Although the bone did suffer postmortem breakage, the distal end shows little damage. The exposed trabeculae are all rounded and show none of the angular edges associated with postmortem breakage. This irregular end is probably the proximal end of the fracture, which did not reunite. It may be one side of a psuedarthrosis (false joint) or it may be the end of an amputation just above the elbow. It was impossible to make a definitive distinction between these possibilities. One side of a psuedarthrosis can resemble the end of an amputation and the absence of the remainder of the arm and hand could be due to amputation or postmortem destruction. However, the site was carefully excavated and the missing bones were not found.

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In summary, the right arm of Shanidar 1 clearly suffered a serious injury or injuries resulting in multiple fractures of the distal humerus and osteomyelitis of the clavicle. Although the similar degree of healing suggests that these lesions were inflicted closely together in time, it is uncertain if they were simultaneous. It is also uncertain as to whether the small size of the bones is due to the injury occurring in childhood with resultant hypoplasia during growth or to atrophy in adulthood. It is also unclear whether the injuries preceded or followed the change in bone size. Looking at the other lesions in Shanidar 1 may clarify some of these problems. The right foot of Shanidar 1 and its associated distal tibia and fibula showed several lesions. The largely complete left foot was normal, indicating a marked asymmetry in these processes. The right 5th metatarsal shows a well healed mid-shaft fracture. There is a large callus with a slight deformity of the diaphysis (the shaft). While the healed fracture does not appear to have resulted in a loss of function, there is an associated osteoarthritis involving the bones of the ankle, which would have caused limitation or pain on motion. Advanced osteoarthritis of the foot may occur as a result of normal wear and tear but in this case it appears to have been trauma related. Not only is there a fracture in the same foot, but the left foot appears normal. Such asymmetry suggests that the disease followed disruption of normal function by an injury. Similar osteoarthritic changes are seen in the right knee, with exostoses involving the right patella (knee cap). The right patella is also considerably widened compared to the left, indicating remodeling after the onset of arthritis. As in the feet, the unilateral involvement suggested a relation to trauma. The injuries to Shanidar 1 also involved the head. There are healed scars on the external table of the right frontal, suggesting scalp wounds that damaged the periosteum but did not fracture the bone. The primary injury sustained by Shanidar 1 was a crushing fracture to the lateral side of the left orbit, involving the frontal bone and the left zygomatic (cheek) bone. This fracture left a permanent deformation on the left side of the upper face. The lateral margin of the left orbit was flat rather than convex. This

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crushing fracture must have disturbed the contents of the orbital cavity, resulting in blindness in the left eye. The condition of the bone indicates that healing took place long before the death of Shanidar 1. He may well have been totally blind, as traumatic injury to one eye can result in a disorder termed sympathetic uveitis, an immunologic phenomenon damaging the other eye. To prevent this complication in modern cases, a penetrating injury to one eye is often treated by removal of the damaged eye (enucleation), thus preserving vision in the other eye. The exact interrelationship of these multiple injuries and the injury related arthritis is difficult to decipher. All of the fractures occurred years before his death, as indicated by the extensive healing and resorption of callus. Even the osteomyelitis of the right clavicle may have been largely healed and in the process of resorption at the time of death. There are 2 two general scenarios that are speculative but appear reasonable, although the sequence of events within each scenario may have been somewhat variable. In one scenario, Shanidar 1 would have sustained a massive crushing injury to the right side of the body, primarily in the region of the shoulder and arm, perhaps in a rock fall in a cove. A crushing injury is most likely, since an incised wound of this degree would probably have resulted in fatal hemorrhage. Soft tissue injury would account for the infection of the clavicle. The fractures of the shaft of the humerus and the loss of the distal portion would have occurred at the same time. The small size of the arm bones could be the result of hypoplasia if the injury occurred in childhood or of atrophy due to associated nerve injury and/or disuse if the damage had been done in adulthood. Either interpretation is consistent with a prolonged period of survival. The fracture of the right 5th metatarsal probably occurred at the same time as the arm injury. A stress fracture due to abnormal locomotion is less likely, since these usually involve the 2nd or 3rd metatarsal. The right sided arthritis was probably secondary to the trauma, being related to the fractured foot, soft tissue injury and abnormal locomotion.

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In this interpretation, the cranial injuries would be seen as secondary to the crushing trauma to the right side of the body. They may have occurred at the same time, as Shanidar 1 was knocked down on his left side by a blow to the right shoulder. The cranial injuries could also have happened later, as a result of the individual’s inability to get around easily. Alternatively the cranial trauma, primarily the blow to the left side of the face, could be seen as primary and the damage to the body secondary. The blow to the left orbit undoubtedly caused blindness in that eye and probably in both. The blow may also have damaged to the left cerebral motor cortex, directly or indirectly through a disruption of cerebral circulation. This interpretation cannot be assessed directly, as the left frontoparietal region was severely damaged postmortem. Damage to the left motor cortex could have produced partial paralysis of the right side of the body, which in turn could have led to the hypoplasia or atrophy of the upper limb (depending on the age at which the injury occurred) and a weakening of the lower limb. This would have predisposed the limbs to additional injuries, infections and osteoarthritis, in an individual who may well have been completely blind. This hypothesis does not directly explain the loss of the distal right arm and is probably less likely. These interpretations, while speculative, are based on clear evidence of injury. Shanidar 3 was also an adult male. His skeleton, while fragmentary, shows trauma related pathology in two areas, a rib and the right ankle. The head and most of the long bones are missing. The left ninth rib shows a partially healed injury on the superior margin, about 6 cm distal to the angle. The injury consists of a parallel sided groove about 1.5 cm wide. Some healing is seen in the form of bony reaction, exostoses, around the margins of the groove. The parallel sides of the groove and the absence of exostoses within the groove suggest that the injury was caused by a penetrating wound between the 8th and 9th left ribs. The instrument cut across the top of the 9th rib and remained in the cut until the individual died. The instrument was not recovered and probably was lost postmortem when the rib fractured below the groove. The degree of healing suggests that Shanidar 3 survived for several weeks or longer after the wound was inflicted. A penetrating injury at this

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level and angle could have punctured into the left side of the chest and underlying lung, creating a pneumothorax and partial collapse of the left lung. Secondary complications may have caused death or he may have been incapacitated and unable to avoid a rockfall in the cave. The remains were displaced by a rockfall but that may or may not have been the immediate cause of death. The angle of the wound makes it unlikely that it was self-inflicted. In fact, the angle and position are exactly what one would expect if a right handed individual stabbed Shanidar 3 in a face to face confrontation. If this interpretation is correct, this is the oldest case of human interpersonal violence, although it could have been accidental. Whatever the circumstances, Shanidar 3 was clearly nursed for at least several weeks and intentionally buried. A recently discovered case is similar. An Egyptian mummy, the Gebelien Man, in the collection of the British Museum, underwent 3 dimensional CT scanning and it was found that he had been murdered 5,500 years ago. He was stabbed in the back rather than the front, with a stab wound identified in his left scapula (shoulder blade) and underlying fractured ribs. This wound would have resulted in a fatal collapse of the left lung. The Gebelien Man was also deliberately buried. Sometime prior to his demise, Shanidar 3 had developed severe osteoarthritis in his right ankle. The fragmentary left foot appears normal, suggesting, as in Shanidar 1, that this asymmetrical arthritis was somehow related to trauma, perhaps a fracture or severe sprain. Shanidar 3 therefore suffered a locomotor disability and died a violent, although perhaps accidental, death. The risk of injury appears to have been high among the Neanderthals for those who lived to an old age. Every currently known and reasonably complete Neanderthal skeleton shows evidence of trauma, suggesting that life in this group was indeed harsh and dangerous. However, the evidence of healing and long life span implies that the Neanderthals had achieved a societal level in which disabled individuals were well cared for by other members of the group. The injuries to Shanidar 1 and 3 probably prevented them from actively contributing to the subsistence of the local group.

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These elderly Neanderthals must have contributed in a more intellectual manner to the group well-being and it is not surprising that many of these individuals were intentionally buried.

Chapter 16

CURIOS, AFRICAN ART AND PALEOPATHOLOGY I have been involved in unusual cases involving paleopathologic techniques. As an extension of this technology, art objects and curios may be composed wholly or in part of human or animal tissues preserved by desiccation. This chapter presents the application of rehydration and histologic study to the assessment of the nature and authenticity of four such items: a South American shrunken head; two skin covered African head crests; and the contents of an 18th century Italian reliquary. Samples from the shrunken head and the African sculpture were rehydrated individually in Ruffer’s solution and fixed in absolute alcohol and embedded in paraffin for sectioning. The relic was embedded in Glycol Methacrylate plastic. Staining included H&E, Masson trichrome for collagen and muscle, and the Kinyoun acid fast stain for hair shafts. The shrunken head, collected in the 1960s by a private individual in the rain forest of Colombia, was assumed to be human. Frank P. Saul, Ph.D. of the Medical College of Ohio, the owner at the time, asked me to keep the head while he was on sabbatical and to examine it for authenticity. A small sample of skin and hair was taken from an inconspicuous spot on the back of the neck. The epidermis was not preserved, but the tissue did contain several large coarse hairs of non-

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human type. Further examination of the hair from the shrunken head was arranged by Patrick Horne, Department of Pathology, Toronto General Hospital and D.M. Lucas, Director of the Centre of Forensic Sciences, Toronto, and performed by Norman Erickson, Head of the Biology Section, Centre of Forensic Sciences. The non-human nature of the hairs was confirmed by the Centre. 16th century Spanish accounts relate that the natives of the tropical jungles of South America produced shrunken human heads, with the skull removed, as battle trophies, with non-human heads substituted when the victim’s head could not be recovered. Sloth heads were shrunken as part of “coming of age” or other rituals. By the 19th century, a counterfeiting industry had developed in response to market demand by museums and private collectors, using the heads of unclaimed paupers, as well as sloth and other animal heads. Histologic examination is thus useful in distinguishing shrunken human heads from those of animals. Theodore Celenko, Jr of the Harrison Eiteljorg Collection of African, Oceanic, and Native American Art in Indianapolis asked me to examine the two African head crests in their collection, which came from southeastern Nigeria. One of these was a two faced, or “Janus-headed”, crest and the other was a crest with a single face and a spiral coiffure. Both pieces, dated to the early 20th century on stylistic grounds, are made of carved wood with a skin covering and include pigment, bone, fiber and basketry. While these art objects were historically believed to have been covered with human skin, by the 20th century animal skin was said to have been substituted. A small sample was taken from an inconspicuous area of the skin covering the two head crests. The tissue covering the Janus-headed crest was collagen with a few interspersed poorly preserved muscle fibers. The epidermis was not preserved. One small melanin pigmented human-type hair shaft was seen, with a suggestion of a surrounding follicular structure, also containing melanin. The covering of the other head crest, with the spiral coiffure, consisted of collagen and poorly preserved muscle, with no hair or other identifying features.

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In contrast to the shrunken head, the skin covering the African carvings is probably human. It appears that the use of human skin continued into the 20th century. Talbot, in writing about his visits to southeast Nigeria, indicated that human skin, probably from slain enemies, was used to cover carved wooden heads. These reports, while usually accepted by scholars, have been questioned by some who may find the possibility distasteful. Our study provides additional support for Talbot’s original observations. The reliquary was privately owned by Dr. George McLaughlin, Sacred Heart and Montgomery Hospitals, Norristown, PA. It consisted of a 4 cm. diameter circular brass box, with a wax seal and an accompanying certificate of authenticity. A glass window showed a 4 x 2 mm. fragment of tan material, said to be bone from the cervical spine of St. Alphonsus of Ligouri. Alphonsus was an 18th century lawyer and theologian who developed a profound cervical kyphosis (hunchback). Despite this and other infirmities, he remained active as a priest and scholar of canon law and had been proposed as a patron for the handicapped. The reliquary was opened and the fragment removed. The “bone” fragment from the relic was plastic embedded and sectioned, showing the typical open pore structure of wood. Despite a Church seal on the reliquary and an accompanying certificate of authenticity, the “relic” was a piece of wood. It was thus impossible to make a diagnosis of tuberculosis, which had been thought to account for paintings showing the saint with a marked cervical kyphosis. The application of rehydration and microscopic examination to these objects demonstrates how the laboratory can come to the aid of the arts. These techniques, derived from the paleopathologic study of mummified tissues, can be employed in assessing art objects and curios containing tissues of uncertain origin. Indeed, even in matters of faith, scientific investigation is warranted. “Things are Seldom What They Seem”. Sir William Gilbert, H.M.S. Pinafore

Chapter 17

HELMSMAN’S ELBOW: AN OCCUPATIONAL DISEASE OF THE 17TH CENTURY Occupational stress is often manifested in the skeleton by unusual patterns of degenerative arthritis or fractures. While more acute disease usually does not affect the skeleton, the skeletal changes of chronic occupational stress are an area of study with significant potential application to archeology. This chapter presents a case in which the relationship between skeletal pathology and the occupation of a deceased sailor is identified by integration of historical, archeological and medical information. The skeleton under study was recovered from a 17th century Swedish warship, the Vasa. Threatened by a large navy built by the Catholic Habsburgs during the Thirty Year’s War (1618-1648), Protestant Sweden undertook the construction of a powerful Swedish Navy. The Vasa was one of the last vessels built under a system developed by King Gustav II Adolf (1611-1632) for contracting out the construction of ships. The ship was begun in 1625 and launched in 1627. In the spring of 1628 the ship was moved from the Royal Navy Dockyard to a position below Stockholm Castle, where she was ballasted and armed. The Vasa carried a total of 64 cannon and was to have a full crew of 145 sailors and 300 soldiers.

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On Sunday afternoon, August 10, 1628, the Vasa began her maiden voyage, intending to take station on one of the outer islands of the Stockholm archipelago. The ship sailed from the quay below the castle in full display of her might, with sails set and all gun ports open. She went only 1,300 meters and 15 minutes out into Stockholm harbor when a sudden squall heeled her so far to the leeward, port side that water flooded in through the open lower cannon ports. As the ship rapidly filled with water, the ballast shifted and she capsized and sank, with sails set and flags flying. The finest ship in the Swedish Navy, one of the largest ships of her time, had gone to the bottom in her own harbor, with many of her crew aboard, along with members of their families, who had been allowed to travel the first few miles of her trip. Luckily, the full military contingent of 300 soldiers had not yet embarked. According to contemporary sources, only between 30 and 50 people died, the flotilla of small boats surrounding the site having rescued many of those who jumped or had been thrown into the water. The effect of the loss of the Vasa on Sweden was not unlike that of the 1986 Challenger disaster on the United States, including the convening of a Court of Inquiry. Testimony of the surviving commanders and the shipwrights suggested a design failure, resulting in a top-heavy, poorly ballasted ship, making her liable to capsizing and with the lower row of gun ports too close to the waterline. However, the cause of the disaster was never officially established and no one was punished. A number of other large 16th and 17th century warships are known to have suffered fates similar to that of the Vasa. In retrospect, the sinking was probably due to incorrect balance on board of heavy weights, ballast and cannon. The ship settled on her bottom at a depth of 32 meters, where she remained despite a series of salvage efforts. Built to impress, the Vasa had exuberantly carved ornamentation and powerful armament, including her 64 bronze cannon. In 1664, most of the cannon were retrieved, using a primitive diving bell and grappling hooks, but the ship was eventually forgotten and lay in the frigid mud for centuries. In the 1950s, Anders Franzén, a Swedish engineer and specialist in wrecked naval vessels, began a systematic search of the harbor floor, in the belief that the ship would be

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preserved by the cold brackish conditions, which are inimical to the shipworm (Teredo navalis) usually responsible for the destruction of wooden ships. In 1956 a core brought up a wooden plug and the ship had been located. 328 years after her sinking, the decision was made to raise her. The Vasa was almost ideal for this effort, as she was the oldest fully identified ship in the world and had not suffered damage from sea duty or battle. In an extraordinary feat of maritime recovery, hard hat divers drilled tunnels in the mud under the ship and cables were passed through and fastened to pontoons. The pontoons were then flooded, the cables tightened, and the pontoons pumped out, raising the ship out of the mud. The rig was then towed closer to shore and the procedure was repeated until the Vasa broke the surface on April 4, 1961, 333 years after her sinking. The hull was sealed by divers and the ship pumped out, allowing her to float and be towed into a dry-dock for a lengthy preservation and restoration process in a specially constructed museum, the Vasavarvet, in Stockholm harbor. In the spring of 1988 the Vasa was taken on her last voyage to a new permanent Vasa Museum in the harbor. The construction site of the Vasa is visible from the windows of the museum, which is only a few hundred meters from the spot where she capsized. The human skeletal material from the Vasa was recovered from both within and outside the hull. After a brief preliminary examination by Professor Nils-Gustaf Gejvall, the bones from inside the ship were reburied in 1963, in sealed plastic bags in concrete coffins, while the bones from outside the hull were never reburied. In connection with the construction of the new, permanent Vasa Museum, a renewed examination of the remains became of urgent interest and after nearly 26 years, the Vasa grave was reopened in May, 1989. Several skeletal elements were in rather poor condition and there was fungal contamination of many bones, as no preservatives had been used. Some of the bones show patches of vivid blue coloring, due to extensive encrustation by iron phosphate precipitated from the numerous iron objects on board the ship. The bones were carefully cleaned with water and 95% ethanol and dried before examination. The remains were subjected to osteological, anthropological and odontological

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analysis. 25 individuals, 20 adults and 5 juveniles, were identified, 16 from inside the Vasa and 9 from outside the hull. One of the adults was a female, 1 was probably male and 18 were males. One of the juveniles was male and 1 was female. 3 of the juveniles could not be identified as to sex. The adult males varied in age from 20 to around 60 years, with an estimated mean stature of about 167 cm. Isotopic and chemical analyses were carried out in order to study dietary differences. Pathologic changes were evaluated by gross morphologic examination and standard radiological studies and a full report was issued by Ebba During (now deceased) in 1994 The skeleton we examined is referred to as that of “the helmsman”, having been found in the helm area near the steering mechanism. He was a 20-22 year old man, now displayed in the Museum with the name given of Filip. It is one of the best preserved and most complete skeletons from the ship. Cranial abnormalities are limited to the dentition, which shows persistent lateral deciduous mandibular incisors (‘baby teeth”) and enamel hypoplasia of the permanent teeth. All the post cranial elements are entirely normal, with the exception of the humeri, each of which demonstrates an almost symmetrical smooth based indentation of the trochlea. The smooth margins indicate that the lesions occurred premortem. The right one is the larger, measuring 11.11 mm long, 8.79 mm wide and 5.04 mm deep. The left one is more ovoid, measuring 11.08 mm long, 4.77 mm wide and 5.04 mm deep. The radiographs of the distal humeri clearly show the defects in each trochlea, with a smooth base in each lesion, seen as a thin sclerotic margin. No other lesions were identified radiographically. In particular, the two ulnae and radii show no abnormalities of their articular surfaces. The lytic lesions seen in the distal humeri are typical of osteochondritis dissecans (OD), a tangential fracture of articular cartilage or cartilage and underlying bone, which is caused by acute or chronic shearing, rotatory or impaction forces. OD occurs at an average age of 17 years to 23 years with an age range of 4 to 47 years and a male preponderance of 85% to 90%. It occurs most often (85%) in the knee and less often in the patella (kneecap), talus (ankle), femoral head and humeral head.

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OD is uncommon in the elbow. In a total of 198 reported cases of OD of the elbow, 189 involved the capitulum and 7 the radial head, 1 the ulna and 1 the trochlea. Most cases are solitary but lesions may occasionally be multiple, either in separate sites on the ipsilateral side or bilateral. The right elbow is affected in 70% to 75% of the reported cases. The fate of the chondral or osteochondral fracture fragment is variable. It may remain attached, resorb, separate from the bone and enter the joint space as a loose body, or attach to the synovium, usually with subsequent resorption. Radiographically, modern cases have a variable appearance. If the osteochondral fragment separates and becomes a loose body, there may be an indentation on the subarticular surface of the bone with a smooth margin. The margin of the defect appears non-sclerotic in acute or early healing lesions and becomes sclerotic as healing occurs or in chronic lesions. In cases in which the osteochondral fragment remains attached, there is a radiolucent line at the base of the fracture. Fractures of the radiolucent cartilage cannot be diagnosed on the conventional radiograph and such fractures cannot be observed in older postmortem specimens, as the articular cartilage is not preserved. OD of the elbow may be asymptomatic but it usually causes pain and tenderness in the joint with some limitation of motion and eventual muscle weakness and disuse atrophy. Loose bodies may calcify and become larger, interfering with function and in a modern patient requiring surgical removal. The gross and radiological picture seen on the humeri of the helmsman, including the smooth base and sclerotic margins of the lesions indicative of healing, are diagnostic of OD. The loose body that arose from the trochlea in life was not preserved in the recovered skeleton. The unique feature of this case is the bilateral involvement of the trochleae. Osteochondritis dissecans has also been identified in the skeletons of sailors recovered from the Mary Rose, an English warship that sank in 1545 A.D. under similar circumstances. The disorder is clearly related to the hard manual labor associated with operating a large sailing vessel. The unique aspect of the lesions identified in the presumed helmsman of the Vasa is the pathogenesis and possible relationship to his occupation. The

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steering mechanisms of ships, known as the helm, have undergone an evolutionary process, beginning with the earliest form of a simple oar suspended from the after part of the ship, on the right (steer-board or starboard) side. In the 14th century the centerline rudder and simple tiller still used on small boats was developed. As ships became larger, it became necessary to add a high poop deck to give the helmsman a line of sight to work the tiller. With the development of larger cannon, additional decks were added in an effort to improve range and the tiller was now below decks and out of sight. A device called the whipstaff was developed to allow the helmsman an enhanced line of sight. The whipstaff was a long pole attached to the tiller and swiveling in a rounded hole in the overlying deck. This mechanism offered a minimal mechanical advantage and the rudder could not be turned very far. The steering of old sailing ships was thus chiefly achieved by manipulating the sails, the steering wheel not being used on larger ships until the 18th century. As turning the rudder increased water resistance and decreased speed, the main task of the helmsman of a ship such as the Vasa was to hold the rudder steady, resulting in a rigid position of the arms and abnormal pressure on the elbows. The helmsman of the Vasa, although still young, must have been a man of considerable experience to warrant his having been chosen for the honor of steering the new flagship of the Royal Swedish Navy on her maiden and, as it turned out, fatal voyage. Filip, devoted to his duty, stayed at his post, a few feet from a ladder to safety, even as the ship was sinking around him. Maintenance of the locked arm position for long periods of time, probably since the helmsman’s teen years, is considered the most likely cause of this unusual occupational disease.

Chapter 18

THE SALEM WITCH TRIALS: JOAN OF ARC AND ERGOTISM In 1985 I was asked by Larry R. Sherman of the Department of Chemistry, University of Scranton to collaborate on a study of the possibility that ergotism was a factor in the Salem Massachusetts witch trials of 1691-92. Ergotism is a type of food poisoning caused by the toxin ergotamine produced by the ergot fungus (Claviceps purpura) that grows on rye. Ergotamine is an alkaloid similar to the hallucinogenic drug LSD (lysergic acid amide), whose properties were described by Albert Hofmann in 1943. LSD is more hallucinogenic than ergotamine but less lethal. Both compounds can be detoxified at high temperatures by prolonged boiling, as in the preparation of porridge, but not in the normal baking of bread. The fungus grows best when the winters are colder and damper than normal, when summers come late and the May to June temperature varies between 17.4-18.9o C. Modern storage and quality control virtually prevents any occurrence of the disease, although detectable levels of the toxin have been found in breakfast cereals as recently as the 1980s. The epidemic form of chronic ergot poisoning due to the ingestion of contaminated grain was most commonly seen at time of harvest but often

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occurred in late winter or early spring following the rye harvest, most commonly in the northern portion of Europe and in European Russia. It was also common in New England during the 17th and 18th century. Ergot fungi appear on unthreshed grain as easily identified clumps of grey spores, but become much more difficult to identify following mixing with other rye kernels during threshing. The fungus is almost always present in small quantities on rye and by itself is relatively harmless. If grain is exposed to moisture during storage or placed in a silo prior to adequate drying, the fungus continues to grow and produces toxic levels of ergotamine. During milling and baking the toxin is transferred unchanged from grain to bread and, depending upon the toxin concentration, it can impart a pink to red coloration to the bread. The toxin is also present in beer made from contaminated grain and can be transferred to nursing children through their mothers’ milk. A slight chemical change in ergotamine yields a toxin that produces death through seizures or neurological dysfunction; other derivatives cause vasoconstriction (blood vessel narrowing) that can lead to “dry”, i.e., noninfectious, gangrene. During the sixteenth century, extracts of the ergot alkaloid were used to induce contraction of the uterus and facilitate childbirth. Ergotism is manifested by a sporadic low fever, usually not more than a degree or two above normal. Symptoms may include nausea, vomiting, and diarrhea and the victim usually suffers from hallucinations (visions). Gastrointestinal symptoms, such as the abdominal pain and bloody diarrhea seen in other types of food poisoning, rarely appear. As a result, food poisoning was usually discounted in the past in cases of ergotism and the disease was often confused with influenza and cholera, even though these diseases produce high fevers and cause death through hyperthermia (elevated body temperature). Since a person with ergotism may suffer diarrhea, death may occur from dehydration and the stench associated with ergot death is similar to that observed with cholera or bubonic plague. Ergotism may persist for months but unlike diseases caused by bacteria and viruses, the survivors of ergot poisoning do not develop immunity.

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Because the symptoms are similar to those observed for other diseases, ergotism was difficult to diagnose in the past without considering patients’ eating, drinking and travel patterns prior to death. Before 1750 CE there were no special medical criteria for ergotism and most deaths or sickness were attributed to other causes. During the latter part of the 18th century, a great deal of effort was put forth to identify and prevent the disease. In 1760, the Russian Army instructed its purchasing agents to reject rye containing more than 15% ergot infested kernels. The Russian Army was the first major organization in the world to control the type of rye used for baking bread. However, ergotism was prevalent during the French Revolution of the 1790s and remained prevalent in Russia throughout the 19th century. The last documented severe epidemic occurred in the Soviet Tartar Republic in 1944 when several hundred people died. Until the mid-19th century, good health was a privilege of the wealthy. The wealthy ate white wheat bread, fresh meat and unspoiled fruits and vegetables. The remainder of the population ate whatever it could acquire, e.g., moldy bread, spoiled vegetables and tainted meat. Ergotamine appears to have been responsible for many of the “plagues” that ravaged Europe during the Middle Ages and was probably second only to bubonic plague in the eradication of entire communities. Although the Black Death (bubonic plague) of 1348-50 was a demographic disaster from which Europe did not recover for over a century, recorded reoccurrences of the plague often present descriptions that are questionable and many reoccurrences of the plague cannot be associated with rats. When the temperature is below 20°C, rat fleas, the host carrier for the bubonic plague microbe (Yersinia pestis), become dormant on the rats. Many of these “plagues” may actually be severe epidemic chronic ergotism. Furthermore, the mycotoxins in ergotic grain would kill rats along with the humans. Since morbidity from ergot rye is highest in August immediately after the rye harvest or in the early spring, unusual times for infectious diseases that usually occur in winter, under conditions of crowding, or in early summer when insects and microbial hosts are most abundant, many epidemics occurring at the wrong time could very likely be ergot food poisoning. A number of plagues during the early fifteenth century can be

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diagnosed with a high degree of certainty to fit into this category. Areas less dependent upon rye as a staple grain exhibited less ergotism, which was true in the 19th and 20th centuries as eating patterns changed. Like LSD, ergotamine affects the central nervous system and hallucinations are one of the main characteristics in about 30% of its victims. The nervous system symptoms were believed in the past to have been caused by supernatural causes, with Satanism as its most common name. Witch trials, which followed accusations of Satanism, predominantly occurred throughout Western Europe where rye was the staple starch and in wet areas after a bad rye harvest. Religion did not seem to dictate where the trials occurred. They are found in both Catholic and Protestant areas of Europe but were absent from areas like Ireland where the peasants subsisted primarily on potatoes, oats and milk. Witchcraft claims were often characterized by animals behaving wildly, probably because hogs and cattle were also affected by the ergot toxin, and with death among young humans, all non-random physical occurrences. This pattern is typical of ergot poisoning, which affects the entire population, including animals, in grain producing areas. Witches were usually identified as individuals isolated from society and living in poverty. Community herbalists often cured the bewitched individuals, especially with motherwort and mistletoe, which were effective against the convulsions and spasms observed in ergot poisoning. Ergotism probably accounts for the events that led to the Salem Witch Trials in 1691-92 in Massachusetts. The key witnesses in the trials were eight girls, who suffered “distemper” in December, 1691. Physicians examined the girls but could find no explanation for the malady. In February, 1692, one of the doctors suggested that the girls might be bewitched and on February 29, the girls made an accusation against Tituba, a Barbados slave, and two elderly women of general ill repute in Salem Village. The three women were taken into custody and put to death, along with seventeen others prior to September 17, 1692, when the death penalty was suspended. In May, 1693, the Governor, Sir William Phips, ordered a general reprieve and ended the whole affair.

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The Massachusetts spring and summer of 1691 were ideal for fungus growth. Storage of the rye grain was poor on the farm where several of the girls lived. The autumn was damp and throughout the winter of 1691-92 the girls’ households depended heavily on a rye diet. When warmer weather arrived in the spring of 1692, the household diet probably changed, for the girls’ distemper disappeared. Other occurrences of ergotism (visions, Satanism, etc.) documented throughout colonial times in New England were almost always associated with a bad grain harvest. Some historians deny the ergot theory in connection with the witch trials because of the factionalism that existed in Salem Village at the time; the accused and accusers were of the two different political factions. Furthermore, during the Massachusetts Governor’s inquiry in 1696, the girls confessed to lying. The reverse stand by the girls during the inquiry was not in character with the original testimony and one feels that the girls were coerced into confessing to a lie but may have still believed in their experience. The general feeling of the scientific community is best summarized by Caporael, “Without knowledge of ergotism and confronted by convulsions, mental disturbances and perceptual distortions, the New England Puritans seized upon witchcraft as the best explanation for the phenomena.” A legend in the Middle Ages may have led to a belief that people who fractured the consecrated communion host would cause it to bleed. Ergot rye imposes a red coloration on bread when it is baked. Although canon law stipulated that communion hosts must be prepared from white wheat flour, which would not show the red coloration, peasants who saw the red rye bread and were taught that the host “was Christ’s blood” could easily transfer the concept of the red coloration in rye bread to a “bloody” host and give rise to the legend. During the French ergot epidemic of 1789, many peasants experienced visions. They had eaten rye immediately after the grain harvest, when ergotamine was at its maximum toxicity. Prophesies abounded among the peasants, statements such as “Elias returns, I see Him,” “I see God,” or “Christ’s 1,000 year reign will now begin,” being common among the peasants. Other spiritual awakenings, where vision and conversions

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occurred (as in New England in the fall, 1741) were also documented along with crop failures or bad rye harvests. The visions seem to follow a pattern suggesting that the spiritual ecstasy may have been hallucination caused by ergotism. Joan of Arc (1412-31), the French Catholic peasant girl, experienced a number of visions during the spring of 1425, as seen in the George Bernard Shaw play, “St. Joan” and the 1948 Ingrid Bergman movie, Joan of Arc. Joan, who was 13, heard voices, saw lights and experienced the presence of St. Michael, St. Margaret and St. Catherine. In 1428, she was persuaded to act in the affairs of the King of France by those who considered her visions to be the work of God. In late summer of that year, during the siege of Orleans, she again had visions and heard more voices. Her experiences typically occurred during a time of famine, poverty or poor health practices. At other times, when she was well fed, she did not experience any spiritual ecstasy. During the decade that she experienced her visions, wheat crops failed one year after another and rye was the only guaranteed crop for the peasants. Because of the strong dependence of the peasants and French army upon rye, it is highly likely that Joan’s visions were hallucinations due to ergotism. Joan’s visions are similar to those experienced by users of LSD and in known cases of ergot poisoning. Skeptics have accused Joan of inventing her stories. Most liars break down when faced with severe challenges or at least make major mistakes in regard to their stories. Victims of drug hallucinations rarely do this and Joan’s unswerving defense of her visions until her death would indicate that the experiences were real to her and typical of the visions caused by ergot poisoning. In many ways, Joan’s revelations parallel those of the girls in Salem in 1692. Numerous saints are listed in the Christian calendar as “fools-forChrist,” e.g., Blessed Andrew, Fool-for-Christ at Constantinople (d. 936 CE). In the unedited versions of the lives of these holy people, where superstition and fact are intermingled, the description of their visions are characteristic of ergotism. Many of these fools-for-Christ lived by begging and eating the discards of other Christians and may have often eaten contaminated grain considered unpalatable by the wealthier population.

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The visions they reported are easy to understand if the fools suffered from ergotism. Russia, where a largest number of the fools for Christ resided, suffered more from ergotism than any other nation, as rye was the staple starch and the ergot fungi grow well in European Russia. Finally, one must look at the Apocalypse written by St. John the Evangelist while he was exiled on the Isle of Patmos. As a prisoner, John was forced to eat whatever his captors fed him. As Patmos’ grain was imported from large grain growing areas like the Danube basin, John may well have been fed ergot contaminated rye bread. It is known that poor grain was fed to Roman prisoners. If ergot contaminated bread had been given to John, one can speculate that he had experienced visions under the influence of the toxin. The visions would be very real to him and would have greatly influenced his traditional scribe, Prochorus, in writing of John’s visions. Careful comparison of his visions in the Apocalypse and those experiences by other individuals suffering from the disease show a great deal of similarity. A skeptic once remarked, “Visions and miracles are much less frequent in our times than in times gone by.” As modern scientific evidence shows a strong relationship between ergot rye and visions, the reduced occurrences of visions and miracles are seen to be due as much to change in standards of living as anything else. Introduction of the potato as a basic starch and the decrease on the dependence on rye as a staple food, especially among the poor, probably resulted in a lower incidence of food poisoning, less infant deaths, higher fertility, a growing population and fewer visions.

Chapter 19

20TH CENTURY PALEOPATHOLOGY: A TRAIN ROBBER AND A PRESIDENT Paleopathology has been found to have a number of applications in more recent work. A body or portions of a body do not have to be hundreds or thousands or year old to become desiccated. I have been involved in two studies that involved much more recent material, ranging from the early 20th century to November 22, 1963. An early 20th century case of trauma relates to one Elmer J. McCurdy, who had a brief career in crime and a longer, postmortem career in show business. My role in this study was somewhat peripheral, in that I was asked to review microscopic slides related to the autopsy of a body from 1911 that had been embalmed in arsenic. Dr. Thomas Noguchi, the Coroner for Los Angeles City/County, had contacted the Paleopathology Association in 1977 regarding an autopsy he was planning on Elmer, who robbed a train on the night of Oct. 11, 1911 that was thought to be carrying several thousand dollars in Indian tribal payments. Unfortunately, Elmer was doomed to an early death by his inability to read the train schedule properly. The gang hit the wrong train and the cash box contained only $46.00. After drinking several bottles of beer, they departed with some demijohns of whiskey.

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With a posse on his trail, Elmer arrived at the Revard Ranch in the Osage Hills, a locale described by the Oct 8, 1911 Bartlesville (OK) Daily Enterprise as an area in which, “...escaped criminals are able to disappear for days at a time, regardless of the advanced civilization made during the past two or three years. Ranches have been converted into farms in nearly every section of the New State (Oklahoma) with the exception of Osage County, where that district outside of the developed oil belt contains every element of wildness that it did in the old territory days.” When Elmer arrived at the ranch, he “...had one of the jugs of whiskey taken from the train by the robbers and had been drinking heavily.” He gave the man at the ranch an alias (Frank Amos) and told him that the whiskey had come off the train that was held up below Okesa. After drinking with the ranch employees for an hour he asked for a place to sleep and was shown to the hay mow. After he had been asleep after only a few minutes, the posse who had been trailing him for two days arrived. They took their stations about the barn and waited for daylight. Bob Fenton (one of the posse members) telephoned the Enterprise that morning about the fight. “It began just about 7 o’clock,” he said. “We were standing around waiting for him to come out when the first shot was fired at me. It missed me and he then turned his attention to my brother, Stringer Fenton. He shot three times at Stringer and when my brother got under cover he turned his attention to Dick Wallace. He kept shooting at all of us for about an hour. We fired back every time we could. We do not know who killed him... (On the trail) we found one of the jugs of whiskey which was taken from the train. It was about empty. He was pretty drunk when he rode up to the ranch last night.” Elmer’s body was brought into Guthrie and turned over to the local undertaker for embalming and burial. Elmer was embalmed in arsenic, resulting in the preservation of the body. Decomposition of the body is due to enzymatic activity present in the cells of the body itself and in bacteria present in the body. These enzymes are inactivated by heavy metals, such as arsenic, in the same way respiratory enzymes are inactivated by poisons such as arsenic. Arsenic is a superb embalming agent but presents such

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serious health risks that its use as such has been banned since early in the 20th century. It wasn’t until 1976 that Elmer’s postmortem career came to light. A television crew was filming an episode of a popular show, The Six Million Dollar Man in the Laugh in the Dark Funhouse at the Nu-Pike Amusement Park in Long Beach, California. A dummy hanging from a gallows was painted with a phosphorescent red paint that glowed in the dark when a nearby ultraviolet light was switched on. A technician moved the dummy and its arm fell off, revealing a bone sticking out of a body. When police were called they questioned the funhouse manager, who was rather distressed to find that the dummy was in fact a mummy. An autopsy performed in the LA Medical Examiner’s Office revealed that body was of an adult Caucasian male and X-rays made it obvious that not only was it human, but that it was a homicide, with part of a bullet in the pelvis! The abdominal and thoracic organs and the brain were hardened to a stone-like consistency. There was a gunshot entrance wound in the right anterior chest, penetrating the right 6th rib, right lung, diaphragm, liver and intestine. A copper bullet jacket, or gas check, was found embedded in the pelvis. Ballistic examination of the jacket revealed it to of a type discontinued before WWII and gas checks were introduced around 1905. Meanwhile, the Long Beach Police Department continued their questioning of the funhouse manager, who was now utterly dismayed when he was informed that the body was a possible homicide victim. He told the investigators that the mummy had been displayed in a coffin in the Hollywood Wax Museum, another concession in the amusement park. When the museum operators defaulted on their rent, he had taken over the mummy, which he thought was made of papier mâché. Within a few days, it was established that the mummy had been a starring attraction in a number of traveling shows and exhibits such as “Louie Sonney’s Museum of Crime” and “Craft’s Carnival Circus.” It had been scheduled for permanent exhibit at the “Haunted House on Mount Rushmore” but was rejected as not being sufficiently life-like!

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The trail finally ended at the Johnson Funeral Establishment in Pawhuska, OK, The undertaker apparently had believed in H.L. Mencken’s observation that nobody ever lost money by underestimating the taste of the American public. As Elmer had no known relatives, instead of burying him the undertaker kept Elmer in a back room of the funeral parlor for several years. For a nickel, local curiosity seekers were admitted to view Elmer, billed as the “Bandit who wouldn’t give up.” Lacking television, the early 20th century population was not able to view violence and death in the comfort of their living rooms. Elmer’s show business engagement in Pawhuska ended about 1916 when a stranger came to town and paid his nickel to see Elmer. He emerged from the back room in tears, claiming that Elmer was his longlost brother and demanding that the body be released to him for burial in the family graveyard in Kansas. The undertaker, fearing legal action, released the body. The stranger, however, wasn’t his brother and he didn’t bury the body. The stranger was a carnival operator and Elmer was launched on tours of the western states in sideshows for many years before winding up in the Laugh in the Dark Funhouse. Like his more famous Oklahoma contemporaries, Will Rogers, Tom Mix, Gene Autry and Woody Guthrie, Elmer went to movie land, hanging around Hollywood for a few years before getting his big chance. Unlike them, he blew his guest shot, on The Six Million Dollar Man, and literally went to pieces on the set. With no next-of-kin or an antemortem physical description as a basis for a positive identification, Elmer faced cremation under his official LA County Coroner’s case number, 76 14 812, Doe, John 255. Fortunately, word of his predicament had spread to Oklahoma, where sentiment favored bringing him home. Local Oklahoma historians found Elmer’s physical description and mug shots made when he entered the OK Territorial Prison. In the University of Oklahoma’s Western History Collection there were two photos of Elmer taken in Pawhuska after his death. One is a full length frontal pose showing him before embalming, still wearing the clothing in which he was shot. The second, taken after embalming, is a profile view, showing Elmer dressed in a black suit, laid out on a bier. Both photos are labeled with Elmer’s name, that of the photographer and

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the date. It appears that they were used not only to help identify Elmer formally, so that the deputies could claim their reward, but were also sold or passed out as souvenirs of the occasion. A committee of prominent Oklahomans contacted Dr. Noguchi, regarding the possible release of the body for burial in Oklahoma. Dr. Noguchi agreed that this could be done if that a review of the available information by a team of experts could establish the identity of the mummy as Elmer J. McCurdy and that Elmer would be given a decent and dignified burial in Oklahoma. Enter the Paleopathology Association (PPA) in 1977, stage right. Forensic anthropologists Dr. Clyde Snow (Chief, Anthropology Research Unit, Civil Aero Medical Institute, Federal Aviation Administration, Oklahoma City, OK, now deceased) and Dr. Judy Suchey, (California State College, Fullerton, CA), members of the PPA, spent two days reviewing the documentary evidence and the mummy. In Elmer’s prison description, a “scar 2 inches long on the back of the right wrist” was noted. Although it was hard to see because of shrinkage and wrinkling of the skin, there was a slender scar running obliquely across the back of the mummy’s right wrist. The facial profile of the mummy was compared with the profile photo of Elmer taken shortly after his death. A forensic medicine superimposition technique, using two video cameras circuited through a special effects generator into a single monitor, was used. One camera was trained on an enlargement of the photo and the other on the mummy and it was immediately evident that Elmer’s profile and that of the mummy were remarkably coincident, strongly supporting the other evidence. These findings, the ballistic evidence, the use of arsenic, and the bullet track matching the description of Elmer’s fatal wound established his identity. On this basis, Dr. Noguchi signed a California death certificate, allowing for Elmer’s return to Oklahoma. Dr. Theodore A. Reyman, Chief of Pathology, Mt. Carmel Mercy Hospital, Detroit, MI and I were asked to participate in the microscopic examination of the tissues, which showed, as was expected, excellent preservation. The hemorrhagic bullet track through the lung was identified.

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As Elmer was young, there wasn’t much in the way of disease, but he had gotten some bad pork at one time and had trichinosis. He also had a fairly rare condition affecting some of his blood vessels, Monkeberg’s medial sclerosis, which causes calcification of the muscle in arterial walls and narrowing. Elmer was met in Oklahoma City on April 4, 1977 by a delegation from the Oklahoma State Medical Examiner’s Office. The expenses, including a modest metal casket and tombstone, were covered jointly by the Indian Territorial Posse of Westerners, an organization of prominent Oklahomans interested in the state’s colorful history, and by the OK Historical Society. The following week Elmer was taken in an old fashioned horse drawn hearse with glass sides and velvet curtains, accompanied by a mounted escort of the OK Territorial Posse, to the Summit View Cemetery at Guthrie, the old territorial capital of Oklahoma. This cemetery, one of the oldest in the state, contains the graves of several notorious outlaws and many prominent early pioneers, ranchers and politicians, leading to an anonymous proposal of this epitaph (fortunately not accepted): Rest in peace, dear Elmer, Beneath this Okie sky, Where many an outlaw slumbers And politicians lie. At the insistence of the OK State Medical Examiner, Dr. Jay Chapman, 2 cubic yards of concrete were poured over the casket, assuring that this native son would wander no more. Another study relates to someone from the opposite end of the socioeconomic spectrum from Elmer McCurdy. In 1998 I was called upon by the National Archives and Records Administration (NARA) and the FBI to participate in a study of some of the evidence in the assassination of John F. Kennedy. Kennedy was shot while in a motorcade in Dallas on November 22, 1963.

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The official report of the Warren Commission was that there were three bullets fired by Lee Harvey Oswald, a mentally deranged Marine Corps deserter and defector, who was killed several days later by Jack Ruby. Oswald’s first shot missed the car, the bullet hitting the pavement and spraying spectators with gravel. The second went through Kennedy’s neck and then entered the back of Texas Governor John Connally, who was in car with Kennedy and their wives. That bullet passed through Connally’s chest and wrist, lodging in his thigh. The third bullet was the fatal wound, destroying Kennedy’s skull and brain. Fragments of this bullet were recovered from Kennedy’s body and the floor of the car. Ballistic examination of the bullets, performed by the FBI, determined that they had come from Oswald’s rifle, and the bullets were then put in storage in the National Archives and Records Administration (NARA) in Washington, DC. Because of continuing interest in the assassination, President Clinton established an Autopsy Records Review Board (ARRB) in 1994, headed by a federal judge. There are over 1 million pieces of evidence and documents relating to the assassination on file at the Archives, all of which was scheduled to be released to the public in 2017, when sensitive information such as the names of CIA and foreign agents will no longer be of relevance. The role of the ARRB was to review requests for access to specific items and determine if they can be released. In its four year life span, the ARRB released about 20,000 items of evidence. One researcher had requested to see the bullets, which were kept in a sealed container. He noted that there were fragments of dark material in the container and NARA thought that these might be fragments of tissue that had not been noted at the time of the initial ballistic investigation. They called my colleague J. Lawrence Angel at the Smithsonian Institution, who directed them to me. I was asked to rehydrate these 35 year old fragments and determine whether they were human tissue. The specimens consisted of 4 roughly triangular fragments of dark brown material, each measuring approximately 3 mm in greatest dimension and 1-2 mm in thickness, and were said to have become detached from the bullet sometime in the past. The surfaces were irregular and slightly reflective in incident light. The specimens were bisected under sterile

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conditions and one half of each was submitted for rehydration and microscopic examination. A core was taken from each of the other halves for DNA analysis. The remaining portions were preserved for possible future study. These minute specimens, accompanied by two Secret Service men, were sent for processing to the laboratory of the Armed Forces Institute of Pathology (AFIP), under the direction of Dr. Jerry D. Spencer, M.D. the Armed Forces Medical Examiner, who collaborated with me on this study. Microscopic examination of specimen 1 showed small fragments of flattened eosinophilic material resembling superficial epithelium. No nuclei were seen. There are small intracytoplasmic PAS granules suggestive of glycogen. Other stains are noncontributory. The impression was human superficial skin. The sections of specimen 2 showed eosinophilic material containing several parallel slender fragments of PAS positive material in a thick walled cellular configuration that was not of human origin. These appeared to be the legs of a postmortem insect (or possibly saprophytic fungal) invader. The intervening material contained small aggregates of orange material appearing to be blood. Other stains were noncontributory. The impression was human tissue and blood with postmortem insect invasion. The sections of specimen 3 showed flattened superficial epithelium with well-preserved nuclei. The PAS stain showed glycogen granules and the trichrome stain showed a thin layer of positive material, possibly underlying muscle. Other stains were noncontributory. The impression was human skin. The sections of specimen 4 showed fragments of amorphous unidentifiable eosinophilic tissue with a few small aggregates of black pigment. No nuclei were seen. Other stains were noncontributory and the impression was unidentifiable tissue and black pigment. The final report was that this material consisted of human tissue in varying states of preservation. The skin in specimen 3 was extraordinarily well preserved, and in number 1 somewhat less so. The tissue in specimens 2 and 4 could not be specifically identified and may have been muscle or brain. Number 2 showed invasion by foreign material, probably an insect.

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Examination by an entomologist or mycologist at the Smithsonian Institution might have provided further identification but was not considered to be germane to this study. After identification of the material as human tissue, one of the aims of the study was to perform DNA analysis, comparing the results from the tissue to the President’s, using blood from his shirt or possibly a sample from Senator Ted Kennedy or the President’s son (both of whom were still alive at that time). However, the material was found to be badly contaminated. DNA analysis operates by greatly multiplying the DNA that is found, preferentially replicating the most complete DNA in the material. DNA laboratories have to take extreme measures to prevent contamination, such as maintaining the air pressure in the laboratory higher than the outside areas. Having been handled by a number of people over 35 years, this material was found to be badly contaminated. It has been returned to the Archives for possible future studies, if DNA techniques can be further refined. Until then, the material is in a “safe place under the care of top men”. At this point in my lectures, I show the film clip from the end of the movie, Raiders of the Lost Ark, where the Ark is put in a locked box and placed in a giant warehouse.

Chapter 20

THE MANCHESTER MUMMY PROJECT The University of Manchester’s KNH Centre for Biomedical Egyptology is the first specifically designated research facility for the investigation of Egyptian mummies in the world. It was officially opened in 2003 by His Royal Highness, the Earl of Wessex. The Centre hosts a multidisciplinary team of researchers and students experienced in many different areas of science, medicine and Egyptology. The department is designed to bring together the many facets of Egyptological research, forming a major resource for this discipline. The University of Manchester’s involvement in this field can be traced back over a century. In 1907 Dr. Margaret Murray undertook one of the earliest scientific unwrappings with the dissections of 2 Middle Kingdom mummies at the Manchester Museum, known as the Two Brothers. This work was taken up again in 1972 with the development of the Manchester Mummy Project and the creation of a mummy team. The Centre represents the culmination of 32 years of research in this field at Manchester, under the initial direction of Professor Rosalie David, OBE, whose research interest led to the development of a new university specialization, biomedical research in Egyptology. Although originally confined to the 17 mummies housed at the Manchester Museum, the project quickly expanded as other museums and institutions volunteered their mummies for scientific

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examination. After Dr. David’s semi-retirement, Dr. Anthony Freemont has continued this new approach to understanding the civilization of ancient Egypt. In 2009 I donated my 40 year collection of paleopathology material, consisting of 3,000 microscopic slides and a number of Egyptian and Alaskan mummy tissue specimens, to the Centre’s International Mummy Tissue Bank, along with Sir Marc Armand Ruffer’s collected papers and other books on Egyptology. I was then invited by Dr. David to be a Visiting Professor for the spring semester, 2010. My wife Barbara and I spent that semester in the UK as a Visiting Professor at the KNH Centre for Biomedical Egyptology. We reviewed this material, which involved my re-examining the slides and verifying the diagnoses (many of which, as is often the case in studying ancient material, were “No Pathologic Diagnosis”). Barbara, an Adjunct Professor in Villanova University’s Computing Sciences Department, created a data base, initially in Microsoft Excel, which was entered into the Centre’s records. I gave a full semester lecture course in Paleopathology and Egyptology for graduate students and faculty in the Centre’s ongoing programs in Science in Egyptology. I examined some of their collections and published a paper with Dr. David in Nature Reviews Cancer on the history of cancer, titled Cancer: A New Disease, an Old Disease, or Something in Between? The gist of our paper was that the modern incidence of cancer is significantly higher than that documented in paleopathologic material. In fact, there are only three histologically documented cases of cancer in the paleopathologic literature. The group at Virginia Commonwealth University diagnosed a rare muscle tumor, rhabdomyosarcoma, in a Peruvian child and I reported rectal and bladder cancer in two Egyptian mummies of the Dakhleh Oasis (Chapter 7). We believe that the modern incidence of cancer is attributable to an increase in carcinogens in the modern world, particularly due to tobacco usage and industrial pollution. This publication has resulted in some controversy, which is of course one of the goals of any research, namely the inspiration of continued research. I was also invited to collaborate with Dr. David, Director of the KNH Centre and Dr. Norman MacLeod, Keeper of Paleontology,

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Natural History Museum, London, in an ongoing project, funded by a 3 year $1 million Wellcome Trust Grant, “Sir Grafton Elliot Smith and the Archeological Survey of Nubia: their significance to the palaeopathological tradition.” This project involves the production of a digital archive and reexamination of some 20,000 Egyptian skeletons and mummies brought to England in the early 20th century. The following year, we came back to Manchester to give an intensive two day course: The History of Disease: Evidence from Ancient Egypt and Beyond, focusing on the integration of Egyptology and paleopathology. The beginning lecture provided an introduction to the medical background needed to understand the significance of findings in mummies, as illustrated in visits by ancient Egyptians to their primary care swnw (physician). The next part of the course covered the significance of findings in Egyptian mummies. The history of the scientific examination of mummies was noted to be a relatively recent phenomenon, starting in the late 19 th century, with a marked expansion in the second half of the 20th century and continuing in the 21st with the application of modern technology such as computerized tomography and endoscopic guided biopsy. A dual focus is the role of disease in its relationship to living conditions in Ancient Egypt and how information derived from mummy studies provides information on the history of disease in humans. As utilization of the material through Excel was somewhat limited, the Manchester Mummy Project website was developed by Barbara and her Villanova University Computing Science graduate students, Sukeerthi Shaga, Pavitra Kaveri Ramnath, and Sai Phaneendra Vadapalli. Barbara has a wide variety of computer experience in aerospace and financial services fields, specializing in database design, including collaborating with me in mummy studies. Barbara currently teaches Computing Sciences courses at Villanova University and her research interest is in applying computer science to the liberal arts. The collection of microscopic slides and paraffin blocks, which is housed in Manchester, offers researchers a treasure trove of materials in which to study the prevalence and history of disease in ancient populations.

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As there was limited accessibility to the materials, a database was constructed with a website front end in order to make the data available to researchers around the world. The database and website, constructed at Villanova University, contains the description of each individual slide, photomicrographs where available and relevant publications. Researchers can request loans of slides of interest to their particular study. The database, which covers one aspect of the Centre’s study of living conditions, health and disease in ancient Egypt, is accessed through the internet at http://manchestermummy.org. This brings the user to the main search screen with 4 possible selection choices: Country, Site, Organ, and Diagnosis. From this screen, the user can search the entire collection by allowing all the defaults of an “all” setting to stand. If the user wishes to, this search can be narrowed to a particular country such as “Egypt” by pulling down on the Country selection. By leaving the rest of the selection fields as “all”, the entire collection of Egyptian specimens will be shown. Further narrowing can occur by selection of a specific archeological site. An organ, for example the “Heart”, can be selected. If “Heart” is selected but all else is left as “all”, each specimen involving the heart, no matter which country, site, or diagnosis, will be displayed. The same procedure can be used for a diagnosis. For example, all cases of cirrhosis will be displayed by selecting that diagnosis and leaving all other fields as “all”. Once the selection is made, the “Go” button at the bottom is clicked and a list of slides will appear. Information will include history, provenance of the site and any publications in which the slide is referenced. One or more photo micrographs are shown if they were taken. Microscopic slides are available for borrowing. A request can be placed using the database by utilizing a tab on the Search screen labeled “Loan”. The same screens are used until the very last screen. At the bottom the user clicks the “Select Slide” button. This brings the user to a page that asks for “name, institution, etc. The user fills out the information and submits the request by clicking the “Submit Request” button at the bottom of the screen. The directors at The University of Manchester KNH Centre will communicate directly with the requester.

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The database itself is implemented using open source software of PHP and MySQL. Open source means that the software can be downloaded from the Internet at no charge. The benefit of using open source software is that it is easily transferable to other institutions. It is hoped that the database will prove useful to researchers and we solicit comments for enhancements. Please contact [email protected] or the KNH Centre: http://www.knhcentre.manchester.ac.uk.

Chapter 21

ANTARCTICA’S FROZEN SEAL MUMMIES AND THE SPREAD OF TUBERCULOSIS Tuberculosis is a world-wide, chronic disease caused by Mycobacterium tuberculosis, which usually affects the lungs but can involve any organ. Tuberculosis is a disease of poverty, malnourishment and inadequate medical care. Although it was the leading cause of death in the early 20th century, the mortality in developed countries has declined greatly, initially due to better living conditions and later by antibiotic therapy. In the U.S., the disease had become primarily one of the elderly, with reactivation of old disease, until the recent increase in cases in patients with Acquired Immunodeficiency Disease/Human Immunodeficiency Virus (AIDS/HIV). In 1969, the US Surgeon General testified to Congress that it was time to “close the book on infectious disease”. In fact, infectious disease remains the largest cause of death in the world and among the infectious diseases tuberculosis is the leading cause of death. Tubercle bacilli are strict aerobes, which become dormant but remain viable in necrotic and calcified lesions, where they can persist for decades. Spread through the lung can lead to involvement of distant organs including the skeletal system. Involvement of the vertebral bodies results in tuberculous kyphosis (hunchback, or Pott’s disease). Skeletal

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tuberculosis is seen in about 1% of cases today. In the pre antibiotic era, this figure was probably 5 to 7%, with the spine the most common site of involvement. Tuberculosis is well documented in dynastic Egypt, with depictions of individuals with the hunchback of spinal tuberculosis. About 3,000 years ago a 6 year old child died after repeated and finally fatal pulmonary hemorrhage due to tuberculosis (Chapter 4). A high frequency of ancient DNA of tuberculosis has been found in bone samples from New Kingdom Egypt. As no cases have been identified from predynastic times, it appears that the human disease developed at the beginning of the historic period of Egyptian history, about 3,000 BCE. The human and bovine forms are closely related to each other so it was initially suggested that with domestication of cattle, Mycobacterium tuberculosis bovis crossed over to humans. Molecular evidence, however, indicates that M. tb. hominis and bovis separated earlier, with the human form coming first. Two independent dating approaches suggest a most recent common ancestor for the M. tuberculosis complex less than 6,000 years ago, which supports a Holocene dispersal of the disease. One point of controversy concerning the history of tuberculosis has focused on the presence or absence of the disease in the New World prior to European contact. Many researchers concluded that the disease had not been present prior to the arrival of Columbus, pointing to the paucity of osteological evidence and the fact that Native Americans proved to be highly susceptible during 17th century epidemics. In 1973, however, a clear case of tuberculosis was found in an undisputed pre-Columbian context, with the presence of tuberculous kyphosis and tubercle bacilli in the 2,000 year old Peruvian mummy of a Nazca child, dating to approximately 77 CE. If New World tuberculosis was due to Mycobacterium tuberculosis, how did it get there? If it was something else, what exactly was it? Once it became generally accepted that some sort of tuberculosis like pathogen had been present in the pre-Columbian Americas, interest focused on characterizing the disease and deciding whether it was: a) caused by Mycobacterium tuberculosis; b) a similar disease caused by an atypical

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mycobacterium (a soil dwelling form) or the bovine form of the organism; or c) some combination of the first two hypotheses. If New World tuberculosis was due to Mycobacterium tuberculosis, how did it get there? If it was something else, what exactly was it? This point is precisely where the study of frozen animal mummies becomes significant. The frozen animal mummies I examined in Alaska (Chapter 10) showed that the preservative effect of freezing and subsequent mummification lasts much longer than had previously been suspected. Most human infections may have originated as zoonoses and in our 1976 report in the journal Science we ended with a suggestion that studies of ancient animal specimens might be able to identify pathogens dating back for many millennia. Recent genomic studies by Kirsten Bos, the Research Group Leader for Molecular Palaeopathology at the Max Planck Institute for the Science of Human History in Jena, Germany, indicate that tuberculosis was spread from Africa by infected seals well before European contact. Techniques in ancient DNA retrieval now allow the sequencing of enough DNA from preserved archaeological tissues so that ancient pathogen genomes can be computationally reconstructed. Diseases from hundreds of years ago can now be identified and their genetic relationships to modern forms determined. So far Dr. Bos has used these techniques to contribute to work on the Black Death, leprosy, cholera and most recently tuberculosis. In a 2014 issue of the journal Nature, Dr. Bos, at that time at the Eberhard Karls University, Tübingen and her colleagues published a paper: Pre-Columbian Mycobacterial Genomes Reveal Seals as a Source of New World Human Tuberculosis. 1,000-year-old M. tuberculosis DNA identified from kyphotic spines from Peru indicated that the disease was present in the New World well before contact with Europeans. The ancient DNA (aDNA) found in these hunchback Peruvian skeletons is most closely related to that found in strains adapted to seals and sea lions and is distinct from modern human adapted forms. Sea mammals may have contracted the disease from an African host species and carried it across the oceans, where exploitation of marine resources by coastal peoples of South America allowed zoonotic transfer. This strain of tuberculosis may have

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then adapted to humans before being replaced by closely related European strains introduced post-contact. Seals frequent the coastline of Antarctica as part of their seasonal migration from Africa to South America. Hundreds of mummified seals have been found in the lifeless Dry Valleys of Antarctica, far inland and as high above sea level. The seals may have become disoriented after waddling ashore and since many of the mummies appear to be juveniles, an undeveloped sense of direction may play a role. They migrated up to 41 miles inland and as high as 5,900 feet above sea level, climbing toward glaciers that sit atop the surrounding mountains, mistaking them for a frozen ocean. The barren landscape of the Dry Valleys is buffeted by katabatic winds, cold winds that can reach up to 200 miles per hour, tearing down from surrounding mountains. The land, striped of moisture, is the largest ice-free region on the continent. A 41 mile journey into the mountains, on loose and sharp gravel, is perilous. Many of the mummies display injuries characteristic of such a journey, showing significant blood loss, wounds and broken bones that may have resulted from a fall off a cliff. Radiocarbon dating indicates that many of these seal mummies are hundreds of years old, with the oldest dating as far back as 2,600 years. The arid conditions and absence of land predators in Antarctica are ideal for natural mummification when seals die. As they made their journey, they eventually starved to death, becoming frozen and mummified. Many of them appear to be completely depleted of blubber and with empty stomachs empty of food. Gravel and sand in their stomachs is a sign of starvation, the seals resorting to eating rocks and sand, as they were trying to eat whatever was available to them. The 6- year-old girl’s mummy that I examined in Alaska showed a similar phenomenon (Chapter 14). She appeared to have died of starvation about 1,000 years ago. Her lower intestine was filled with gravel, sand, pebbles and animal hair, indicated that normal food sources were unavailable. True seals, ideally adapted to a marine environment, are clumsy on land. They cannot pull their hind-flippers forward, and move on land by lunging, bouncing and wiggling while their fore-flippers keep them

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balanced. A 41 mile journey on loose, sharp gravel is quite remarkable. One feels sympathy for these lost seals creeping through the valleys, passing by other carcasses funneled by the landscape to arrive at the same spot over hundreds of years. The story of these lost seals has two redeeming features: the determination of these seals in going on no matter how far lost they became, and how little they could have known that they would play a scientific role in the 21st century. Seals that contracted tuberculosis from an African host species appear to have been carrying the disease across the South Atlantic Ocean. Exploitation of marine mammals by the coastal peoples of South America led to transfer of the disease to humans. The marine mammal form of tuberculosis, which is restricted to the southern hemisphere, is now identified by Dr. Bos as the cause of the New World human disease long before European contact. Our ongoing studies of modern and ancient seals are expected to clarify the history of transmission of the disease. Dr. Daniel Nývlt, a geologist at the Masaryk University in the Czech Republic, has recently returned from Antarctica, where he collected bone samples from these seals. The samples have been delivered to Dr. Bos to confirm their role in transmitting the disease to the New World. One of my favorite quotes is from Niels Bohr, the Nobel Prize physicist, “Prediction is very difficult, especially about the future.” These ancient mummified seals may very well help my 40 year old prediction come true.

EPILOGUE: ACKNOWLEDGEMENTS Looking back, why did I want to study paleopathology? My medical career as a pathologist meant that that I was a consultant to every doctor in the hospital and that every patient was my patient. Fascinated by the history of humanity and looking for an even more universal approach to the issue of health care led me to consider the cultural and historical aspects of disease and medicine and a desire to supplement my training with anthropology. I feel that I did achieve my goal, in combination with service to humanity as a physician. Through paleopathology I’ve journeyed from Alaska through Egypt to Antarctica. As a charter member of the Paleopathology Association I believe that I played a significant role in the now worldwide awakening of interest in the field. As noted in the preceding chapters, we now have a much better understanding of the history of many diseases. Atherosclerosis, the leading cause of death in developed countries, has been found to have a much longer history than previously believed. Cancer appears largely to be a disease of modern industrialized and tobacco using society. One hopes that this information will lead to better preventative medicine. My dual career would not have been possible were it not the support and guidance of many people in both fields (many of whom are retired or no longer with us). These include: J. Lawrence Angel, Don Ortner and T.

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Dale Stewart of the Smithsonian Institution; Arthur Aufderheide, University of Minnesota Medical School, Duluth; Alan Mann, Baruch Blumberg, Sol Katz, Frank Johnston, Lanny Bell and Reuben Reina of the University of Pennsylvania Anthropology Department; Aidan and Eve Cockburn; Al Reyman (who contributed much of the material on Elmer McCurdy in Chapter 19); Pat Horne; Peter Lewin; Jens Peder Hart Hansen; A. Rosalie David of the University of Manchester’s KNH Centre for Biomedical Egyptology; Ebba During; Fred Becker of the New York University School of Medicine; Stan Cohen, who steered me to WRAIR; Colonel Helmuth Sprinz, Director of WRAIR; Gentry Yeatman; Enrique Gerszten and Marvin Allison of the Medical College of Virginia; Larry R. Sherman, Bob Brier and my many coauthors and pathologist colleagues. Any omissions or errors are entirely my responsibility. My most sincere acknowledgement is to my wife Barbara, who has kept all the notes for these many studies, first with pencil and paper and now into a computer database and web site, as well as providing photography. She unfailingly supported me through medical school, pathology residency and graduate school, while combining caring for our two daughters with serving and protecting our country through her career in aerospace.

GLOSSARY Adenocarcinoma

a malignant tumor of glandular origin

Adenoma

a benign tumor of glandular origin

Aneurysm

enlargement of an artery

Ankylosis

fusion of joints

Arteriosclerosis

thickening and hardening of arterial walls

Ascariasis

an intestinal parasitic worm infestation

Atherosclerosis

plaque buildup in arteries

Autolysis

destruction of cells by their own enzymes

Callus

healing tissue around a bone fracture

Calvarium

the superior aspect of the skull

Chondrocytes

cartilage cells

Clivus

part of the skull base

Cocci

round bacteria

Coprolites

fossilized feces

Dermis

tissue underlying the skin

Emphysema

lung disease due to over inflation of the air sacs

Endocarditis

infection of heart valves

Eosinophilia

parts of tissue staining with the pink dye eosin

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Epiphyses

the ends of long bones

Erythrocytes

red blood cells

Fibrous histiocytoma

a benign skin tumor

Fluorochrome

fluorescent substance used in biological staining.

Gamma Globulin

blood protein that forms antibodies to antigens such as bacteria or viruses

Glomeruli

the filtering structures of the kidney

Gram Stain

staining technique for identification of bacteria

Granulomas

inflammatory infiltrates formed when the immune system is unable to eliminate foreign organisms or materials

Hematopoiesis

production of the cellular elements of the blood

Hemosiderin

breakdown product of hemoglobin

Hepatocytes

the functional cells of the liver

Hyperkeratosis

thickening of the superficial layer of the skin

Hypertonic

having a higher osmotic pressure than a body fluid or intracellular fluid.

Hypoproteinemia

low protein level in the blood

Idiopathic

of unknown cause

Infarction

death of tissue due to lack of blood

Mandible

the lower jaw

Mastoiditis

inflammation of the bone behind the ear

Maxilla

the upper jaw

Meninges

membranes surrounding the brain

Meningioma

a benign meningeal tumor

Meningitis

inflammation of the meninges

Metatarsal

bones of the mid-portion of the foot

Myocardium

heart muscle

Necrosis

death of tissue

Glossary

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Neonatal

the period immediately after birth

Obsidian

volcanic glass

Ossicles

small bones of the inner ear

Osteocytes

bone cells

Osteoid

the organic component of bone

Osteoma

a benign bone tumor

Osteons

functional units of compact bone

Osteophytes

bony outgrowth at degenerated joints

Osteoporosis

a weakening of bone

Osteosarcoma

a malignant bone tumor

Paleodemography

study of the influences on the lifespan and health of pre-modern populations

Paleoepidemiology

study of the distribution of diseases in ancient populations

Papilloma

a small, usually benign, wart like growth on the skin or a mucous membrane

Papilledema

swelling of the optic nerve inside the eye because of increased pressure in or around the brain

Perineum

the area between the anus and the scrotum or vulva

Pneumoconiosis

lung disease caused by dusts deposited deep in the lungs

Portal Areas

part of the liver containing blood vessels and bile ducts

Pulmonary edema

fluid in the lungs

Pyelonephritis

kidney infection

Renal medulla

kidney tubules

Retroperitoneum

the area behind the abdominal cavity

Rickets

bone disease due to Vitamin D deficiency

Rods

elongate bacteria

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Schistosomiasis

infestation by a Schistosoma species of parasitic worm

Sciatic notch

notch in a pelvic bone, the ilium, useful in skeletal sex determination

Sickle cell anemia

abnormal red blood cells

Sigmoid sinus

a venous sinus just below the brain

Silicosis

accumulation of silica in the lungs

Splenomegaly

enlargement of the spleen

Squamous epithelium

skin

Stratum corneum

the most superficial part of the skin

Stroma

the structural part of tissues

Subdural hematoma

blood surrounding the brain

Trachoma

bacterial infection of the eye

Viscera

organs

Zoonoses

disease transmitted from animals to humans

Zygoma

cheek bone

BIBLIOGRAPHY Adamson, PB. 1976. Schistosomiasis in Antiquity. Medical History 20:176-188. Aldred, C. and A.T. Sandison 1962. The Pharaoh Akhenaten: A Problem in Egyptology and Pathology. Bulletin of the History of Medicine 36:293316. Allison, M.J. 1985. Chile’s Ancient Mummies. Natural History 94(10):7481. _____, Gerszten, E., Martinez, A.J., Klurfeld, D. and A. Pezzia. 1977. Generalized Connective Tissue Disease in a Mummy from the Huari Culture (Peru). Bulletin of the New York Academy of Medicine 53:292301. _____, Mendoza, D. and A. Pezzia. 1974. A Radiographic Approach to Childhood Illness in PreColumbian Inhabitants of Southern Peru. American Journal of Physical Anthropology 40:409-416. _____, Pezzia, A., Gerszten, E. and D. Mendoza. 1974. A Case of Carrion’s Disease Associated with Human Sacrifice from the Huari Culture of Southern Peru. American Journal of Physical Anthropology 41:295-300. _____, Pezzia, A., Gerszten, E. Giffler, R.F. and D. Mendoza. 1974. Aspiration Pneumonia due to Teeth - 950 AD and 1973 AD. Southern Medical Journal 67:479-483.

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_____, Pezzia, A., Hasegawa, I. and E. Gerszten. 1974. A Case of Hookworm Infestation in a PreColumbian American. American Journal of Physical Anthropology 41:103-106. _____, Mendoza, D. and A. Pezzia. 1973. Documentation of a Case of Tuberculosis in PreColumbian America. American Review of Respiratory Disease 107:985-991. Artamonov, M.I. 1965. Frozen Tombs of the Scythians. Scientific American 212, #5:101-109. Armelagos, G.J. 1969. Disease in Ancient Nubia. Science 163:255-259. Aufderheide, A.C. 1985. The Enigma of Ancient Cranial Trepanation. Minnesota Medicine 68:119-122. _____, Angel, J.L., Kelley, J.O, Outlaw, A.C., Outlaw, M.A., Rapp, Jr., G. and L. E. Wittmers, Jr. 1985. Lead in Bone III. American Journal of Physical Anthropology 66:353-361. ______ and C. Rodriquez-Martin. 1998. The Cambridge Encyclopedia of Human Paleopathology. Cambridge: Cambridge University Press. _____, Lorentz E., Wittmers, Jr., L.E., Rapp, Jr., G. and J. E. Wallgren. 1988. Anthropological Applications of Skeletal Lead Analysis. American Anthropologist 90:931-936. _____, M. Zlonis, L.L. Cartmell, M.R. Zimmerman, P. Sheldrick, M. Cook and J.E. Molto. Human Mummification Practices at Ismant El-Kharab. Journal of Egyptian Archeology 85:197-211, 1999. Bakay, L. 1985. An Early History of Craniotomy. Springfield, IL: C.C Thomas. Barfield, Lawrence. 1994. The Iceman Reviewed. Antiquity 68(258):10-26. Beattie, O. and G. Geiger. 1987. Frozen in Time. Bloomsbury, London. Benitez, J.T. 1988. Otopathology of Egyptian Mummy PUM II: Final Report. Journal of Laryngology and Otolology 102:485-490. Bell, Lanny. 1973. In the Tombs of the High Priests of Amun. Expedition 15, #2:17-27. Bennike, Pia. 1985. Paleopathology of Danish Skeletons. Copenhagen, Akademisk Forlag. Bianchi, R.S. 1983. Egyptian Mummies: Myth and Reality. Archeology 35:8-25.

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______, Sandison, A.T. and P.H.K. Gray, 1969. Human Biological Observations on a Guanche Mummy with Anthracosis. American Journal of Physical Anthropology 30:333-347. Budge, E.A. Wallis. 1972. The Mummy. New York: Collier. Brothwell, D. 1972. Digging up Bones. London: British Museum of Natural History. Brothwell, D. 1968. The Skeletal Biology of Earlier Human Populations. Oxford: Pergamon Press. Brosch, R., S. V. Gordon, S.V., Marmiesse, M., Brodin, P., Buchrieser, C., Eiglmeier, K., T. Garnier, T., Gutierrez, C., Hewinson, G., Kremer, K., Parsons, L.M., Pym, A.S., Samper, S., van Soolingen, D. and S. T. Coleet. 2002. A New Evolutionary Scenario for the Mycobacterium Tuberculosis Complex. Proceedings of the National Academy Science of Science USA 99, 3684-3689, 2002. Campbell, G.F. 1962. The Neophyte Shipmodeler’s Jackstay. Bogota, New Jersey.Model Shipways. Cano, R.J., Tieffenbrunner, F., Ubaldi, M., Del Cueto, C., Luciani, S., Cox, T., Orkand, P., Künzel K.H. and F. Rollo 2000. Sequence Analysis of Bacterial DNA in the Colon and Stomach of the Tyrolean Iceman. American Journal of Physical Anthropology 112:297-309. Caporael, L.R. 1976. Ergotism: The Satan Loosed in Salem, Science 192:21-26. Carlson, D.S., Armelagos, G.J. and D.P. Van Gerven. 1974. Factors Influencing the Etiology of Cribra Orbitalia in Prehistoric Nubia. Journal of Human Evolution 3:405-410. Celenko, T. 1981. The Harrison Eiteljorg Collection. African Arts 14:3242. ______ 1983. A Treasury of African Art from the Harrison Eiteljorg Collection. Bloomington, Indiana University Press. Cockburn, T.A. 1963. The Evolution and Eradication of Infectious Diseases. Baltimore, Johns Hopkins Press. ______. 1971. Infectious Diseases in Ancient Populations. Current Anthropology, 12: 45-62.

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______. 1973. Death and Disease in Ancient Egypt. Science 181:470 — 471. ______. 1978. Paleopathology and its Association. Journal of the American Medical Association 240:151 —153. ______, Barraco, R.A., Reyman, T.A. and W. H. Peck. 1975. Autopsy of an Egyptian mummy. Science 187:1155-1160. ______, Cockburn, E., and T.A. Reyman, eds. 1998. Mummies, Disease and Ancient Cultures, 2nd ed. Cambridge, England: Cambridge University Press. Comas, I., Coscolla, M., Luo, T., Borrell, S., Holt, K.E., Kato-Maeda, M., Parkhill, J., Malla, B., Berg, S., Thwaites, G., Yeboah-Manu, D., Bothamley, G., Mei, J., Wei, L., Bentley, S., Harris, S.R., Niemann, S., Diel, R., Aseffa, A., Gao, Q., Young D., and S. Gagneux. 2013. Outof-Africa Migration and Neolithic Coexpansion of Mycobacterium Tuberculosis with Modern Humans. Nature Genetics 45, 1176–1182. Cook, M., Molto, J.E. and C. Anderson. 1989. Fluorochrome labelling in Roman Period Skeletons from Dakhleh Oasis, Egypt. American Journal of Physical Anthropology 80:137-143. ______, Molto, J.E. and C. Anderson. 1988. Possible Case of Hyperparathyroidism in a Roman Period Skeleton from the Dakhleh Oasis, Egypt, Diagnosed using Bone Histomorphometry. American Journal of Physical Anthropology 75:23-30. Crubezy, E., and E. Trinkaus. 1992. Shanidar 1: A Case of Hyperostotic Disease (DISH) in the Middle Paleolithic. American Journal of Physical Anthropology 8(4): 411-420. David, A.R and M.R. Zimmerman. 2010. Cancer: A New Disease, an Old Disease, or Something in Between? Invited paper, Nature Reviews Cancer 10:728-733 (advance online publication, 3 Sept. 2010). Deelder, A.M., Miller, R.L., de Jonge, N., and F. W. Krijer. 1990. Detection of Schistosome Antigen in Mummies. Lancet 335(8691): 724-725. Dirk, J.H. 1985. The Biblical Plague of “Hemorrhoids”: An Outbreak of Bilharziasis. American Journal of Dermatopathology 7:341-346.

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AUTHOR’S CONTACT INFORMATION Michael R. Zimmerman, MD, PhD Biology Department, Villanova University, Villanova, PA, US [email protected]

INDEX A abscess, 50 Acquired Immunodeficiency Disease (AIDs), 195 acute tubular necrosis, 121 adenocarcinoma of the rectum, 89 Adenocarcinomas, 66 Adipocere, 38, 39, 63, 212, 216 Adolf, King Gustav II, 165 African head crests, 161, 162 Age determination, 14, 16, 17, 215, 216, 228 Aleut mummies, 68, 120, 124 Aleutian Islands, viii, 33, 34, 120 Aleuts, 33, 34, 40, 41, 123 Allison, Marvin, 4, 29, 202, 207, 217, 220 alpha-l-antitrypsin (AlAT) deficiency, 145, 146, 147 American Museum of Natural History, 111 amino acid racemisation, 6, 7, 14, 16 amputation, 155 Amun of Karnak, 45 ancient DNA, 196, 197 Angel, J. Lawrence, ix, 3, 25, 29, 43, 179, 185, 201, 208, 228

Angel, Larry, ix, 3, 25, 29, 43, 179, 185, 201, 208, 228 anthracosis, 40, 41, 49, 52, 73, 81, 88, 90, 91, 93, 117, 119, 121, 123, 125, 135, 136, 139, 142, 144, 145, 210 anthracotic pigment, 38, 62, 73, 79, 88, 90, 97, 119, 133, 144 anthropophagic animals, 3 aorta, 36, 37, 38, 53, 57, 59, 64, 71, 72, 78, 88, 90, 121, 140 Arctic Health Research Center, 131 Armed Forces Institute of Pathology, 20, 29, 58, 186, 215 arsenic, 134, 179, 180, 183 arsenic poisoning, 134 arteriolar nephrosclerosis, 122 arteriosclerosis, 63, 64, 72, 203 Arthritis, 50, 102, 123, 156, 157, 159, 165, 214, 216, 218, 223 artificial cranial deformation, 19, 223 Ascaris, 71, 89 Aspiration, 135, 207 asymmetrical osteoarthritis, 154 atalectasis, 62 atherosclerosis, 14, 37, 38, 40, 41, 50, 53, 63, 67, 88, 92, 93, 117, 119, 121, 122,

234

Index

123, 124, 125, 133, 135, 136, 140, 201, 203 Aufderheide, Arthur, 27, 28, 138, 202, 208, 212, 222, 225, 226, 228, 229 autolysis, 4, 38, 60, 62, 64, 67, 90, 99, 203 Autopsy Records Review Board, 185

Brothwell, Don, 21, 26, 31, 60, 209, 210, 213, 217, 221, 226 Bruce-Chwatt, L.J., 25 bubonic plague, 172, 173 Buikstra, Jane, 31, 209, 220, 227

C B bacterial abscesses, 38, 39 bacterial endocarditis, 140 Barraco, Robin, 22, 25, 211, 219 Bekenkhons, 45, 47 Bekenkhons I, 45 Bell, Lanny, 44, 45, 46, 166, 202, 208 benign tumors, 50 Bibliography of Human Paleopathology and Related Subjects, 31 bipareital thinning, 50 Black Death, 173, 197 blindness, 108, 150, 157, 158 blood type, 5, 41, 72 Blood typing, 72, 215, 218 bone, 5, 7, 9, 14, 15, 16, 18, 36, 40, 41, 49, 53, 54, 57, 60, 61, 63, 65, 66, 72, 74, 86, 89, 96, 108, 111, 112, 116, 119, 120, 122, 124, 132, 134, 135, 141, 142, 144, 149, 150, 151, 152, 155, 156, 162, 163, 168, 169, 181, 196, 199, 203, 204, 205, 206, 208, 209, 211, 213, 214, 216, 217, 218, 219, 220, 225 Bos, Kirsten, 197, 199, 209 Bradley, Zorro, 131, 227 brain, 9, 10, 36, 37, 38, 48, 50, 57, 60, 71, 77, 78, 79, 96, 103, 112, 115, 117, 118, 121, 133, 150, 181, 185, 186, 204, 205, 206, 218 Breast cancer, 65 Brier, Bob, 209 British Museum, 159, 210, 223 bronchiectasis, 40, 122

calcific mitral stenosis, 140 Canadian Institute for the Study of Egyptian Antiquities, 85 Cancer, 52, 53, 54, 55, 65, 66, 93, 101, 119, 124, 125, 140, 147, 150, 190, 201, 211, 217, 224, 228 Cancer of the prostate, 66 Cannabis, 106 Canopic jars, 9 carcinoma of the lung, 65 caries, 40, 78, 108 cataracts, 92, 93, 108 Černý, Jaroslav, 45 Champollion, 109 Chapman, Jay, 184 chemical analyses, 5, 168 chemical analysis of bone, 18 chicken pox, 70 cholera, 23, 172, 197 cholesterol, 53, 62, 63, 88 Chondrocytes, 40, 59, 60, 203 chronic mastoiditis, 122 chronic osteomyelitis, 61 chronic passive congestion, 65, 68 chronic pyelonephritis, 99 circulation of blood, 103 circumcision, 106 cirrhosis, 59, 79, 80, 93, 98, 147, 192 cirrhosis of the liver, 80 Cockburn, Admiral Sir George, 23 Cockburn, Aidan, 21, 23, 28, 202, 227 Cockburn, Eve, 21, 24, 202, 211, 227, 228 coins, 3

Index comedones, 70 Companion to Paleopathology, A, 31, 226 Connally, John, 185 contraception, 108 coprolites, 37, 40, 203 Copts, 47 corneal scarring, 150 coronary artery disease, 67, 135 coronary atherosclerosis, 67, 133, 135, 136 Coronary thrombosis, 64, 68 corpus luteum, 141 cotton, 73 cribra orbitalia, 50, 210 Cryptocotyle lingua, 134 CT scans, 28, 78, 125, 138, 159 cysticercosis, 80

D Dakhleh Oasis Project, 85, 86 Dating of biological materials, 6 David, Rosalie, 26, 30, 45, 189, 190, 202, 211, 226 decubiti, 70 degenerative joint disease, 50, 54, 121, 122, 124 demography, 1, 218, 225 dendrochronology, 6 dental aging, 18 dental attrition, 35, 36, 40, 117 dental bridge, 108 dental calculus, 36, 40 dentistry, 1, 103, 215, 225 dentists, 103, 107, 108 dislocations, 107 Dra Abu el-Naga, 44, 55, 127, 228 Dry Valleys of Antarctica, 198 During, Ebba, 2, 4, 7, 8, 9, 10, 12, 14, 17, 18, 21, 23, 25, 26, 38, 44, 45, 46, 57, 69, 72, 74, 79, 81, 85, 95, 102, 111, 119,

235 140, 147, 156, 165, 168, 172, 173, 175, 176, 180, 196, 202, 212

E early Egyptian physicians, 102 Ebers papyrus, 102, 104, 105, 106 eczema, 70 edema, 65, 97, 99, 145, 147, 205 Egyptian medical papyri, 3, 101 electron microscopy, 5, 24, 25, 29, 81, 122, 125, 146 electron spin resonance, 6, 7 embalmers, 55, 74, 95, 96, 102 embolization, 65 emphysema, 40, 90, 133, 136, 145, 147, 203 epidemiology, 1, 212 Ergot fungi, 172, 177 ergot poisoning, 171, 172, 174, 176 ergotism, 171, 172, 173, 174, 175, 176, 210, 221 Erickson, Norman, 162, 218 ethmoid plate, 48 excrement, 103, 104, 105, 108 expectoration, 103

F falciparum malaria, 2 fatty change of the liver, 59 fibrin, 64 fibrous histiocytoma, 50, 52, 204 figurines, 3 Filip, 168, 170 fish trematode, 134 food poisoning, 171, 172, 173, 177 forensic medicine, 20, 67, 183 formaldehyde, 4 Formalin, 4, 58 fractures, 50, 53, 65, 74, 75, 107, 115, 116, 117, 118, 121, 133, 134, 135, 136, 139,

236

Index

140, 144, 153, 154, 155, 156, 157, 159, 165, 168, 169, 203, 214, 215, 216, 217, 221 Franzén, Anders, 166, 213 Freemont, 30, 190

G Gejvall, Nils-Gustaf, 167 genetics, 1, 211 Gerszten, Enrique, 29, 202, 207, 208, 217 Global History of Paleopathology, 31 glomeruli, 60, 64, 98, 121, 204 Gologergen brothers, 131 Gooch, P.S., 25 gram-negative bacillus, 38, 39, 41 granite, 79, 81 Greenland, 13, 142 gynecology, 107, 222

H Hall, Charles Francis, 47, 134, 137, 142, 218 Handbook of Archeological Sciences, 31, 226 Hansen, J.P. Hart, 142, 202 Harris lines, 3, 77, 80, 148, 216, 224 Harrison Eiteljorg Collection, 162, 210 healed infarct, 64, 65, 68 heart, 9, 12, 24, 35, 36, 37, 38, 48, 57, 63, 64, 65, 67, 70, 71, 78, 79, 88, 89, 96, 99, 103, 112, 117, 132, 133, 140, 144, 163, 192, 203, 204, 226, 227 heart failure, 65, 96, 99 helm, 168, 170, 228 hematology, 1 hematoxylin and eosin, 5, 58, 59, 97, 112 hemosiderin, 65, 68, 204 hepatic fibrosis, 91, 98, 99 hepatitis, 25, 70, 79, 147

Herodotus, 10, 95, 102 Herophilus, 108 histiocytes, 61 histoplasmosis, 125, 136, 141 history, ix, 1, 19, 23, 26, 27, 28, 31, 53, 76, 97, 103, 111, 182, 184, 190, 191, 192, 196, 197, 199, 201, 207, 208, 210, 216, 219, 221, 224, 225, 226 Homo erectus, 149, 151, 224 Honey, 104, 105, 106, 107, 108, 152 Hooten, Ernest, 21 Horne, Patrick D., 24, 122, 162, 202, 213, 229 Horus-eye, 10 Hrdlička, Aleš, 20, 21, 33, 34, 35 human evolution, 2, 149, 151, 153, 210, 219 hypervitaminosis A, 149, 150, 152, 224

I Iceman, 30, 208, 210 Imhotep, 102 Impetigo, 70 industrial pollution, 190 Inflammatory cells, 22, 61, 70, 145 Institute of Evolutionary Medicine, 30 ivu, 138

J Jensen, Anne, 143, 229 Joan of Arc, 171, 176 Johnson, Lent, 29, 182 Jones, Joseph, 19, 20, 214

K Kagamil Island, 33, 35, 120 Kellis, 85, 87, 129, 217 Kennedy, John F., 184, 185, 226

Index Kennedy, Ted, 187 Kenya National Museum, 149 keratomalacia, 150 kidneys, 9, 37, 57, 59, 60, 70, 71, 79, 80, 96, 97, 98, 117, 121, 122, 123, 141, 144, 204, 205 Kimeu, 149 Klebsiella pneumoniae, 39, 41 KNH Centre for Biomedical Egyptology, ix, 5, 29, 189, 190, 202 kyphosis, 163, 195, 196

L lactation, 141 lead, 18, 50, 73, 119, 124, 142, 147, 172, 195, 201, 208, 212, 221, 224, 225 lead levels, 18, 50, 73, 119 Leakey, Richard, 149, 224 lemming, 111, 112, 113 leprosy, 86, 197, 212, 216, 217, 224 leukemic infiltrates, 66 Lewin, Peter K., 25, 75, 202, 215, 219 lice, 24, 122, 123 lipofuscin, 63, 64, 134 liver, 9, 37, 57, 59, 63, 66, 68, 70, 72, 78, 79, 80, 88, 90, 96, 97, 98, 106, 112, 117, 118, 121, 133, 140, 146, 147, 150, 152, 181, 204, 205, 227 lung, 38, 39, 50, 57, 59, 62, 63, 65, 66, 71, 72, 73, 79, 81, 88, 90, 91, 97, 98, 117, 121, 139, 141, 144, 145, 147, 159, 181, 183, 195, 203, 205, 224 lung cancer, 140 Luxor, Egypt, 44, 75 lymphocytes, 61 Lynn, George E., 26, 212 lynx, 111, 112

237 M

Maat, 9, 103, 215 MacLeod, Norman, 190 magnetic resonance imaging (MRI), 28 malabsorption syndrome, viii Malachite, 105 malaria vaccine, viii Man, Gebelien, 20, 21, 22, 31, 34, 35, 51, 69, 72, 76, 81, 101, 103, 105, 117, 118, 124, 135, 159, 168, 170, 180, 181, 182, 213, 223, 226, 227 Manchester Mummy Project, 30, 189, 191, 225 Manchester Mummy Project website, 191 Masson trichrome, 5, 58, 59, 60, 112, 161 mastoiditis, 50, 122, 123, 204 Max Planck Institute for the Science of Human History, ix, 197 McCurdy, Elmer J., 179, 183, 184, 202, 221 McLaughlin, George, 163, 216, 229 mercury level, 73 metastatic carcinoma, 66 metatarsal, 154, 156, 157, 204 midwife, 104 miracles, 177 Moodie, Roy L., 21 Morse, Dan F., 26, 217 Morton, Samuel G., 19 mummification styles, 6, 11 Murray, Margaret, 29, 189 Museum of Man, 31, 223 Mycobacterium tuberculosis, 51, 195, 196, 210, 211, 225 Mycobacterium tuberculosis bovis, 196 Myers, Wayne, 25, 26, 137 myocardial infarction, 64, 67, 96, 133 myocardium, 59, 64, 65, 67, 88, 133, 204

238

Index N

Nakht, 75, 76, 77, 80, 81, 82, 83, 98, 219 nasopharyngeal carcinoma, 93, 142 National Archives and Records Administration, 184, 185 natron, 9, 10, 25, 81, 96, 97, 105, 209 Nazca child, 196 Neanderthals, 151, 152, 153, 154, 159, 223 Nebwenenef, 45, 46, 47, 128, 228, 229 neonatal pulmonary hemorrhage, 91, 93 neonate, 108 neutrophils, 61, 70 Noguchi, Thomas, 179, 183 Nývlt, Daniel, 199

O obstetrics, 1, 107, 222 Oklahoma State Medical Examiner’s Office, 184 ophthalmologists, 107, 108 orthodontics, 1 orthopedics, 1 Ortner, Don, 24, 27, 28, 29, 201, 212, 217, 222 osteoarthritis, 154, 156, 158, 159 osteochondritis dissecans, 168, 169, 215, 217, 220, 225 Osteocytes, 60, 205 osteoma, 50, 54, 205 osteomyelitis, 61, 62, 156, 157 osteoporosis, 15, 20, 123, 125, 141, 142, 144, 205 osteosarcoma, 63, 205, 223 Oswald, Lee Harvey, 185 otitis media, 72, 122, 123

P paintings, 3, 13, 76, 163 paleodemography, 21, 205 paleoepidemiology, 21, 205 Paleopathology Association, 10, 21, 22, 33, 69, 73, 75, 83, 95, 115, 116, 179, 183, 201, 221, 225, 228 Paleopathology Club of the International Academy of Pathology, 29 Paleopathology Club of the U.S.-Canadian Academy of Pathology, 95 Paleopathology Newsletter, 22, 28, 31, 215, 225, 228, 229 paleoserology, 5, 215 papillary carcinoma, 66 paralysis, 53, 158 parasitology, 1, 55 patella, 89, 156, 168 pathology, vii, 1, 19, 20, 21, 24, 25, 26, 27, 29, 35, 39, 43, 58, 87, 93, 95, 98, 108, 118, 146, 153, 158, 162, 165, 183, 186, 202, 207, 212, 215, 218, 220, 221, 223, 225, 226, 227, 229 Peabody Museum, 20, 33, 115, 116, 120, 124 Peabody Museum at Harvard, 20, 33 Peabody Museum of Archeology and Ethnology, 115 Peck, William H., 22, 26, 211 pediculosis capitis, 122, 123 Pemphigus foliaceous, 71 penetrating wound, 158 perforation of the tympanic membrane, 122 periodontal, 35, 36, 40, 41, 50, 72, 108 periodontal bone loss, 36 periodontal disease, 35, 40, 41, 50, 72, 108 periportal fibrosis, 97, 98 Peruvian mummy, 196, 229 Petrie, Flinders, 21 pharmacists, 104

Index phosphotungstic acid hematoxylin, 5, 64, 98, 112 phrenology, 19 plasma cells, 61 Plasmodium falciparum, 2 plastic embedding of bone, 5 pleural adhesions, 50, 122, 141 pneumonia, 37, 39, 41, 90, 122, 123, 125, 141, 145, 150, 207 pneumothorax, 159 porotic hyperostosis, 19, 20, 218, 222, 224, 228 pottery effigies, 3 proctology, 103 proteolytic enzymes, 3, 61 psammoma bodies, 66 Pseudopathologic changes, 3 psuedarthrosis, 155 Ptolemy III, 47 pulmonary edema, 97, 99, 147, 205 pulmonary hemorrhage, 49, 91, 93, 196 pulmonary thromboemboli, 99 PUM I, 22, 208, 229 Putschar, Walter, 29, 218

Q Queen Hatshepsut, 45

R rabbit, 111, 112 Radiocarbon dating, 6, 7, 34, 69, 115, 198 radiology, 1, 125, 213, 224 Ramnath, Pavitra Kaveri, 191 Ramses II, 45, 62, 75, 127 Ramses III, 75, 127 Rauch, Robert, 132 red blood cells, 59, 135, 204, 206 religious statuary, 3 resin, 9, 10, 48, 49, 51, 54, 71

239

Retinol, 150 Reyman, Theodore A., 22, 24, 183, 202, 211, 212, 215, 219, 221, 229 rhabdomyosarcoma, 190 rheumatic valvulitis, 140 rib fracture, 50, 74, 139, 158 Roma-Roy, 45 Royal Ontario Museum, 25, 75, 85 Ruby, Jack, 185 Ruffer, Sir Marc Armand, 2, 4, 21, 37, 49, 58, 70, 78, 87, 97, 112, 117, 122, 133, 161, 190, 220 Rühli, Frank, 30

S saints, 176, 223 Salem Witch Trials, 171, 174 salvage archeology, 138 Sandison, A.T., 21, 26, 59, 207, 209, 210, 221 Sarcoidosis, 62 Satanism, 174, 175 Saul, Frank P., 161, 229 scalp wounds, 156 schistosomal cirrhosis, 98 schistosomiasis, 25, 55, 56, 80, 88, 89, 93, 94, 206, 207 scoliosis, 49, 90, 91, 133, 136 Scythians, 11, 134, 208 Sea mammals, 123, 197 septicemia, 39, 41 sex determination, 18, 48, 107, 206 Shaga, Sukeerthi, 191 Shanidar Neanderthals, 153, 154, 223 Sherman, Larry R., 171, 202, 221 shipworm, 167 shrunken head, 161, 163, 219 Siberia, 11, 134, 221 sickle cell, 2, 25, 206 silicosis, 72, 74, 117, 206

240

Index

Six Million Dollar Man, 181, 182 skin, 11, 13, 22, 34, 36, 40, 50, 52, 54, 57, 60, 69, 70, 71, 72, 74, 77, 81, 91, 97, 104, 105, 112, 116, 120, 132, 135, 139, 142, 143, 150, 152, 161, 162, 163, 183, 186, 203, 204, 205, 206 skull fractures, 74, 75, 115, 118, 133, 136 sling ball wound, 116, 118 Smith, Grafton Elliot, 21, 53, 63, 107, 132, 191, 209, 221, 227 Smithsonian, viii, ix, 20, 23, 25, 28, 29, 33, 35, 41, 44, 120, 124, 125, 132, 133, 185, 187, 202, 218, 222, 228 Smithsonian Institution, viii, 20, 23, 25, 28, 29, 33, 44, 120, 124, 132, 133, 185, 187, 202, 218, 222, 228 Smithsonian mummy, ix Snake bites, 105, 107 Snow, Clyde, 183, 221 Solecki, Ralph, 153, 222 South Atlantic Ocean, 199 South Tyrol Museum of Archaeology, 30 special stains, 5, 89 Spencer, Jerry D., 58, 186 spina bifida, 50, 53 spleen, 37, 57, 59, 60, 65, 68, 71, 72, 78, 79, 82, 96, 97, 98, 112, 118, 134, 144, 206 splenic rupture, 78 St. Alphonsus of Ligouri, 163 Staphylococcus aureus, 105 starvation, 145, 147, 198 State University of New York at Binghampton, 137 Steinbok, Ted, 29 Stewart, T. Dale, viii, 21, 29, 202, 222 Strouhal, Eugen, 27, 93, 222 styles of mummification, 49 subcorneal pustular dermatosis, 22, 69, 70, 71 Suchey, Judy, 183 suffocation, 12, 136 surgical instruments, 106

sympathetic uveitis, 157

T talipes cavus, 89, 91, 93 tapeworm, 2, 79, 80 tattoos, 6, 11, 12, 13, 132, 142 Tedford, Richard, 111, 113, 229 tertiary dentin, 40 testis, 57, 60, 88 Tetracycline, 105 Thebes, 44, 47, 52 thrombosis, 63, 64, 67 thrombus, 64, 98 thyroid carcinoma, 53 tobacco usage, 190 tomb robbers, 11, 46, 51, 87, 99 trachoma, 108, 206 transitional cell carcinoma of bladder, 91 trauma, 4, 40, 41, 50, 53, 54, 67, 74, 75, 106, 107, 115, 116, 118, 120, 135, 144, 153, 154, 156, 157, 158, 159, 179, 214, 217, 222, 223, 229 Trepanation, 115, 208 trichinosis, 80, 125, 141, 184 Trichuris trichiura, 134, 219 Trinkaus, Erik, 152, 211, 223, 229 Tubercle bacilli, 40, 49, 51, 62, 134, 195, 196 tuberculosis, 26, 49, 51, 52, 55, 56, 90, 91, 93, 113, 135, 141, 163, 195, 196, 197, 199, 208, 209, 210, 211, 213, 214, 216, 217, 220, 225, 227 types of mummification, 10

U University of Maryland Medical Center, 95 University of Pennsylvania, ix, 25, 27, 43, 51, 57, 69, 132, 202, 228 University of Scranton, 171

Index urine, 12, 103, 105, 107

V Vadapalli, Sai Phaneendra, 191 Valley of the Kings, 44, 45 varicose veins, 72 Vasa, 165, 166, 167, 169, 170, 209, 212, 213, 214 Vasa Museum, 167, 209, 212 Villanova University’s Computing Sciences Department, 190, 191 Virchow, Rudolf, 20, 139 Vitamin A, 150, 152 Vitamin A deficiency, 152

W Wade, Nicholas, 95, 209, 229 Wadi Natrun, 96 Walker, Alan, 149, 224

241

Warren, Dr. John Collins, 19, 185 waste disposal, 55 whipstaff, 170 whipworm, 134 Witchcraft, 174, 175 woolly mammoth, 111 World Congress on Mummy Studies, 30

X xerophthalmia, 150

Y Yersinia pestis, 173

Z zoonoses, 23, 113, 197, 206