DAN MORSE, M.D. Research Associate. R. C. DAILEY, Ph.D. Associate Professor and Chairman JENNINGS BUNN

Transcription

1 447 PREHISTORIC MULTIPLE MYELOMA DAN MORSE, M.D. Research Associate R. C. DAILEY, Ph.D. Associate Professor and Chairman JENNINGS BUNN Department of Anthropology Florida State University Tallahassee, Fla. M LJULTIPLE myeloma is a malignant tumor originating in the bone marrow. It is a fatal disease and is usually generalized and extensive. It can involve all the bones of the skeleton but has predilection for the vertebrae, ribs, skull, and pelvis.2 3 According to Dahlin,2 multiple myeloma is the commonest primary malignant tumor of bone. In the Mayo Clinic series, myeloma accounted for 1,286, or 43%, of all malignant primary bone tumors and 32% of all primary bone tumors, both benign and malignant. It occurs more often in males and in the older groups, being most common in those over 5o and rare in those under 40. Solitary lesions occur, but most authorities believe this is a precursor to generalized distribution.2 3 The tumor arises in the marrow spaces and invades the bone, leaving discrete rounded holes of various sizes. These holes have sharply demarcated borders which show little or no condensation of bone. Gross specimens and x-ray reproductions are described as being "punched out," as if the lesions might have been made by a paper-punch. In the long bones, the tumor invades the cortex and eventually reaches the outer surface. In the skull, it starts in the diploic space and progresses into and through the inner table, outer table, or both. The x ray is invaluable for the study of archaeological specimens, since it visualizes defects that have not yet reached the surface of the bone. Clinically the diagnosis is confirmed by biopsy of the tumor. Archaeologically a differential diagnosis would include first an osteolytic carcinomatous metastasis. Discreteness of the individual lesions and extensive distribution favor myeloma. This is even more characteristic in Vol. 50, No. 4, April 1974

2 448 8 D. MORSE AND OTHERS other conditions of the skeleton, such as osteitis fibrosa cystica, histiocytosis X, leukemia, and possibly fibrous dysplasia. In 1932 William Ritchie and Stafford Warren" reported a case of possible multiple myeloma in a prehistoric American Indian. This specimen was derived from a "senile male" and was one of 43 skeletons excavated in 1930 from an Indian site near Binghamton, N.Y. According to Ritchie and Warren,6 the date of occupation of this "Clark" site was about 8oo A.D. Gross and x-ray appearance demonstrated the presence of discrete destructive lesions throughout the entire skeleton. In 1941 Williams, Ritchie, and Titterington7 reported similar lesions in a child, about io years of age, who probably dated from around I200 A.D. Sheilagh Brooks and Jerome Melbye' in I967 described a female skeleton, with an estimated age at time of death of 40 years or more. This individual was excavated from the Kane Mound near St. Louis, Mo., and belonged to the Mississippian culture; the probable occupation date was about I 2oo A.D. All the skeletal elements contained bone perforations ranging in size from 2 to I 7 mm. While examining skeletal material in the R. H. Lowie Museum of Anthropology, University of California, Berkeley, Don Brothwell called attention to multiple myeloma in a prehistoric California Indian. This was reported by met in i969. According to information supplied by Dr. Albert B. Elsasser, the skeleton, that of a female aged 45, was excavated by Ronald L. Olson in I930. The occupation site was known as "site i00," Santa Cruz Island; the estimated date was between 3oo A.D. and 1450 A.D. (Late Horizon). The specimen was riddled with osteolytic lesions of various sizes. In the past few months the staff of the Department of Anthropology at Florida State University has become aware of four additional cases of possible multiple myeloma in prehistoric Americans. The reports follow. SOWELL MOUND In the summers of I967 and I968 the Department of Anthropology at Florida State University conducted salvage excavations of the Sowell Mound, located in Bay County, Fla., near Panama City. More than 20,000 bones and bone fragments were collected. These are believed to be the discards of at least five different archaeological parties, begin- Bull. N. Y. Acad. Med.

3 PREHISTORIC MULTIPLE MYELOMA 44 9 Fig. 1. Sowell Mound skull. Posterior view, showing large myelomatous lesion in occipital bone. ning with that of Clarence Moore, who apparently investigated and excavated more than 40 Indian sites in the northwest Florida coast for a four-month period during the summer of 1902, including the Sowell excavation. The Indian culture represented is most probably Weeden Island; the approximate dates could range between 5oo A.D. and o200 A.D. One carbon dating of the site was submitted by Lamar Gammon. This was derived from oyster shells; the result was: 6i0 A.D. + I25 years. Among the bone fragments found, it was possible to piece together some 26 cranial vaults. One of these (shown in Figure i) is Specimen Number I; it is a cranium without a lower jaw or face. From the orbits Vol. 50, No. 4, April 1974

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5 PREHISTORIC MULTIPLE MYELOMA 4 5 I and the closure of sutures, it is estimated that the individual was a male aged 45. There is a large circular opening on the left side of the occipital bone, measuring 24 mm. in diameter. The hole penetrates both tables; there is no evidence of reaction in adjacent bone. In the right frontal bone there is a circular lesion 8 mm. in diameter. There is a hole measuring 2 mm. in the posterior portion of the right parietal. Both of these penetrate only the outer table of the skull. On the inside of the cranium there are eight openings which range in size from i to IO mm. in diameter and which penetrate the inner table only. X-ray examinations confirm these findings and reveal in addition many indefinite smaller osteolytic areas, representing tumors that had not yet reached the surface. In the long-bone fragments there were five specimens showing evidence of cystic lesions which could be myeloma, but there is no way in which these bones could be matched with the pathological cranium. The cranium is definitely osteosclerotic. This is true of many of the other cranial vaults and quite a few long bones. In addition, in more than Iooo teeth recovered there are no cavities. This suggests that the drinking water may have contained an excess of fluorine. The mound is located in an area occupied by the Naval Coastal Systems Laboratory and has been so altered by recent developments that the source of water used by the aboriginal populations cannot be ascertained. CALICO HILLS, BURIALS ONE AND Two One of the authors (J.B.), undertook salvage excavations in one of the three Calico Hills mounds which is in Jefferson County, Fla., on the west bank of the Wacissa River. It had been destroyed almost totally by a series of previous excavators. Mr. Bunn recovered the remains of eight burials, one of which was a cremation. All the skeletons were incomplete and had been damaged postmortem. They had to be sprayed many times with Krylon in order to prevent complete disintegration. Two of the eight showed evidence of myeloma. From pottery previously excavated it could be determined that the culture was probably assignable to Late Swift Creek and Early Weeden Island. An uncertain estimate of occupation date for the mound would be between 200 A.D. and goo A.D. Calico Hills Burial Number One (Figure 2) is an incomplete, fragmented female skeleton consisting of a cranial vault, some fragments of Vol. 50, No. 4, April 1974

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7 PREHISTORIC MULTIPLE MYELOMA 4 53 skull and face, lower jaw, a few long bones, and some pieces of ribs, vertebrae, scapulae, and pelvis. This skeletal age is about 25 years. Gross and roentgenological examination reveal involvement of all available skeletal elements, with numerous punched-out areas varying in size from I to 13 mm. Taking into consideration changes due to postmortem degeneration, the density of the bones appears to be within normal limits. Calico Hills Burial Number Two (Figures 3 and 4) consists of the top of a skull with part of an occipital bone and one orbit, plus several fragments of skull and facial bones. On the basis of the appearance, this is a female and appears to be young. The age at death might be guessed at 25 years or less. The lesions are numerous. They are discrete, unaccompanied by osseous reaction, and are identical to those seen in Burial Number One. MANGUM MOUND In i963 the Mangum Mound (Site No. MCL 9) in Claiborne County, Miss., on the Natchez Trace Parkway, was excavated by Charles F. Bohannon for the National Park Service. Approximately 62 skeletons were recovered, boxed, and stored. Anticipating publication of the data, the National Park Service contracted with the Department of Anthropology of Florida State University to do a complete skeletal analysis. When the material was prepared for examination, one specimen was found to be extensively diseased. The site has not been dated accurately; apparently it belongs to the Late Mississippian Period, circa 1300 A.D. The burial in question, consisting of nearly all the postcranial bones, was in a separate box and was labeled Burial No. 4. Analysis of these bones suggests that this is a female with an approximate age of 35. The field notes said that Burial No. 4 was a group burial representing four separate individuals. In separate bags were portions of four skulls, each labeled Burial No. 4. All four of the portions of the skull were x rayed; only one was definitely female. It was designated Burial No. 4B. Lesions were revealed by the x ray, and resembled those discovered in the postcranial bones. A description of this skeleton and of "B" skull follows: The postcranial skeleton consists of 21 vertebrae, 34 rib fragments, the pelvis, scapulae, all the long bones, and most of the bones of the hands and feet. The greatest pathological involvement is in the body of Vol. 50, No. 4, April 1974

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9 PREHISTORIC MULTIPLE MYELOMA the seventh cervical vertebra. This vertebra reveals the presence of seven distinct punched-out areas, whose borders show no bony reaction. The areas vary in size from 2 to 7 mm. X-ray examination demonstrates two additional radiolucent areas not seen on the gross specimen, indicating nonpenetration of bone surface. Other vertebrae showing involvement, detected either by inspection or by roentgen examination, are the cervical i, 2, and 3; the thoracic I, 2, 3, 4, 6, 7, 8, 9, ii, and I2; and the lumbar 2, 3, and 5. Other bones affected include I I of the 34 rib fragments, the pelvis, and the right scapula. Skull B (Figure 6) is that of a female about 35 years old. The x ray shows many areas of rarefaction of varied size; these appear to be the same as those seen in multiple myeloma. These are confined mostly to the left parietal bone. These punched-out areas are not detected by simple inspection. The surface of the outer table seems normal. On the inside there is a large circular region of roughened superficial erosion. The lesion appears as if the inner table has been almost completely destroyed. The diploic space is exposed, but there is no extension through the outer table. The area of involvement includes the entire left parietal and the posterior portion of the left side of the frontal; there is some extension past the squamous suture onto the left temporal bone. The borders of this erosion are demarcated by a ridge of what appears to be roughened nodular periosteal proliferation. If this is a large myelomatous area, the tumor could have originated in the diploic space and destroyed the inner table completely. One would expect that it would erode the outer table also, but it did not. Another feature not typical of myeloma is the buildup of osseous nodules on the borders. In addition, this skeleton demonstrates marked generalized osteoporosis. The long bones are feather-light. COMMENT Four cases of possible prehistoric multiple myeloma are presented. Two of these, Calico Hills Burial One and Two, are so typical in appearance that the diagnosis of multiple myeloma is fully justified. In the cranial vault from the Sowell Mound the disease is not as extensive as one would expect and the bone shows marked osteosclerosis, but myeloma is still the best possibility. The Mangum Mound Case (Figure 6) is also most likely one of multiple myeloma, but the atypical lesion on the inside of the skull reduces confidence in the diagnosis. A word should be said about the age. Statistics indicate great rarity Vol. 50, No. 4, April 1974

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11 PREHISTORIC MULTIPLE MYELOMA Fig. 6. Mangum Mound Burial. Inside of skull, showing atypical destruction of large portion of inner table. of myeloma in persons under 40. Three of our four cases were below the age of 40, but one should remember that quoted incidence rates are frequently based on American and European cases and may not necessarily apply to other population groups. A preliminary report of this paper was read at the annual meeting of the American Association of Physical Anthropology held at Dallas, Tex., in May After the presentation several physical anthropologists stated that they had seen many similar cases (unreported) in their pre- Vol. 50, No. 4, April 1974

12 4 5 8 D. MORSE AND OTHERS historic Indian collections. This leads one to the opinion that multiple myeloma in the prehistoric American Indian was not a great rarity. 1. Brooks, S. T. and Melbye, J.: Skeletal Lesions Suggestive of Pre-Columbian Multiple Myeloma. Technical Series No. 7. In: Paleopathology 1, Wade, W. D., editor. Museum of Northern Arizona, Flagstaff, Ariz., 1967, pp Dahlin, D. C.: Bone Tumors. Springfield, Ill., Thomas, 1967, pp. 11, 124, Luck, J. V.: Bone and Joint Diseases. Springfield, Ill., Thomas, 1950, p Moore, C. B.: Certain aboriginal remains of the northwest Florida coast. J. Acad. Nat. Sci. 12:167-74, REFERENCES 5. Morse, D.: Ancient Disease in the Midwest. Reports of Investigations, No. 1. Springfield, Ill., Illinois State Museum, 1969, p Ritchie, W. A. and Warren, S. L.: The occurrence of multiple bony lesions suggesting myeloma in the skeleton of a pre-columbian Indian. Amer. J. Roentgen. 28:622-28, Williams, G. D., Ritchie, W. A., and Titterington, P. F.: Multiple bony lesions suggesting myeloma in a pre- Columbian Indian aged ten years. Amer. J. Roentgen. 46:351-55, Bull. N. Y. Acad. Med.