DOI: https://doi.org/10.5114/pjp.2019.84462 Pol J Pathol 2019; 70 (1): 44-48 R eview paper P aleopathology of s of t tis sues : what mummies can reveal P edro L. F ernández 1 , J ordi E steban 2 , A gustín F ranco 3 1 Department of Pathology, Hospital Germans Trias i Pujol and Universidad Autonoma de Barcelona, Badalona, Spain 2 Department of Pathology, Hospital Clinic, Barcelona, Spain 3 Department of Urology, Hospital Clinic and University of Barcelona, Barcelona, Spain Paleopathology is a science located in a crossroad between history, archaeology, anthropology, and medicine an can offer unique historical knowledge by using techniques of traditional pathology as well as other branches of Medicine, which is especially fruitful when applied to ancient subjects in which soft tissues are preserved: mummies. Key words: paleopathology, mummy. The history of medicine is usually based on written mies require the adoption of a multidisciplinary ap- historical records [1], but sometimes ancient subjects proach [3] including not only anthropology and pos- are actually sufficiently preserved over long periods sibly archaeology but also several sophisticated areas of time, and upon discovery, provide an amazing of medicine such as pathology, microbiology, paleo- wealth of valuable direct evidence of both diseased nutrition, molecular biology, etc. human remains, and more rarely, medical procedures. Paleopathology is a discipline situated at a most History of paleopathology interesting crossroad between history, archaeolo- gy, anthropology and medicine, being therefore in It is known that Herodotus studied ancient mum- a unique position to blend different approaches to mification rites in Egypt, and that, more recently, obtain historical knowledge. Virchows had the opportunity to analyze mummi- Among ancient remains, the most frequent are fied subjects [4]. However, it was great scholars such those consisting of bony samples, sometimes includ- as Elliot Smith, Ruffer, Zimmerman and Aufder- ing full skeletons. These durable samples can some- heide who definitively provided the scientific bases times contain remnants of diseases such as neoplasms, for the development of paleopathology as a modern degenerative processes or even infections which usu- science [4, 5, 6]. A good, recently published sum- ally involve bones. Unfortunately, most human con- mary of the history of paleopathology mentions that ditions do not affect bony tissue and remain undis- the term “paleopathology” was not coined until 1892 covered after careful analysis of bones. by R. W. Schufeldt [7]. The technical advances for Mummies are ancient human or animal remains in the histological processing of mummified tissues which outer or inner soft tissues are, to some extent, provided by Sir Armand Ruffer and Sandison [8, 9]. artificially or naturally preserved (Fig. 1). This usu- were paramount for the study of soft tissues. During ally occurs by a rapid desiccation process, although the last part of the XX and the ongoing XXI century, in some instances humid environments allow other seminal and extensive work in paleopathology, and types of soft tissues preservation [2]. The amount more specifically, in mummified subjects, was under- and quality of possible samples obtained from mum- taken by Aufderheide and Rodriguez-Marin [4, 5], 44 Paleopathology of soft tissues: what mummies can reveal better preservation produces artefacts in these sub- jects that hamper histological examination. Other artificial mummies such as those of the Chinchorro culture, are possibly the oldest known and are dif- ficult to interpret since their preservation was based on stripping soft tissues, disarticulation of bones and ulterior articulation and covering with colorful clays [14]. Some of the best preserved subjects were naturally mummified by rapid cold desiccation, such as the Tyrol man [15, 16] or the Andean child mum- mies [17]. When approaching a mummified subject, the first question is if the degree of preservation is good enough to allow a meaningful study, and this decision is usually based on the extent of soft tissue preservation, the experience of the “paleopatholo- gist” and, finally, the success of the histopathological examination. Another important question is to what extent the mummy can be “harmed” by extraction of its information. For instance, can a full autopsy be performed? Can only small superficial biopsies be obtained? Must the subject be “reconstructed” after the autopsy for exposition?, etc. And, very im- portantly, the possibility of non-invasive techniques such as conventional radiology, computerized to- mography or even magnetic resonance studies [18, 19, 20] should be considered, although the latter is Fig. 1. Mummified woman from ChiuChiu, Atacama De- not the best study technique in dried specimens. In sert (Bolivia). Date unknown. Collection of the Museum some instances, the use of minimally invasive proce- of the Department of Legal Medicine, Universidad Com- dures such as endoscopy using a flexible cystoscope plutense de Madrid, Spain or a flexible fibrogastroscope can provide very useful images and samples [21, 22]. Once the soft tissue is obtained, a technical pro- Fornaciari [10] and Gerszten and Allison from cedure similar to that used in conventional samples the Medical College of Virginia [11, 12], although of fresh tissue can be followed: formalin fixation, several other groups have provided interesting con- paraffin embedding, microtome sectioning and his- tributions to this field [see references 6, 7 and 13 for tochemical staining. Nonetheless, all of this is only a review]. possible if we first return the tissue to a rehydrated state with the use of some simple solutions like those Methods used in paleopathology The term paleopathology has traditionally been related to physical anthropologists given their expe- rience dealing with bony remains. However, the ap- pearance of mummified soft tissues is frequently neglected as an important source of information about human diseases that leave no trace in skeletal remains. In fact, it was a common practice to strip bones of these soft components in order to achieve better access to morphological information from them. Mummies, like any other remains, can have different degrees of preservation, in part depending on the mummification process. Thus, preservation of outer parts of the body like skin and muscles of ar- tificial mummies from ancient Egypt is very good but the inner organs are often lacking due to the classical Fig. 2. Nerve fascicle (center) surrounded by perineuro and practice of evisceration. Also, the use of ointments for skeletal muscle. HE staining, magnification 200× 45 Pedro L. Fernández, Jordi Esteban, Agustín Franco Fig. 4. Positive immunohistochemical staining for actin in a renal vascular wall of an Andean mummy (approximately 500 years old). Hematoxylin/DAB, magnification 200× diseases such as tuberculosis and treponematosis in ancient Egypt and, Helicobacter pylori, malaria, small- pox and different types of parasitic diseases [40-46] Fig. 3. Scanning electron microscopy of white matter from in the pre-Columbian New World are abundant in mummified Bronze Age brain tissue [25] the literature. Other conditions have been described in mummies, including degenerative bone process- es in South American mummies indicating the high of Ruffer or Sandison, which are mainly based on prevalence of vertebral degenerative changes and an alcoholic solution with sodium carbonate [8, 9, the scarcity of metastases to bone in this area [47] 23, 24]. as well as some endocrine pathologies including goi- Samples processed in this way can be then ana- tre [48], tissue deposits as in pneumoconiosis [49] or lyzed with light or even electron microscopy [25] gout [50] and acquired, heritable, nutritional or hor- (Figs. 2, 3). Moreover, if tissue preservation is rela- monal skin disorders [51]. tively good, immunohistochemical staining and mo- lecular tests are also possible (Fig. 4) [23, 26, 27, 28, Seminal studies in paleopathology 29]. Recently, advances in proteomics have succeeded in identifying several proteins related to immune res- There have been many important paleopatho- ponse and inflammation in mummified tissue sam- logical studies since the first in the XIX century, ples, thus providing evidence of active pathogenic therefore, a review of previous extensive studies in infection related to the cause of death [30]. paleopathology would be of great interest [4, 5, 6]. The special relevance of some paleopathological stud- Pathology in mummies ies may lie in the technical advances applied to this discipline, the discovery of relevant pathological con- Different types of pathological conditions have ditions from a medical point of view in a historical been reported in mummies, including both neoplastic context in “common” subjects or in the analysis of fa- and non-neoplastic diseases. Apart from osseous ev- mous historical subjects irrespective of the interest idence of malignancies and benign tumors [31, 32], of the findings. several types of neoplasms such as histiocytomas, ad- Elliot Smith, Ruffer and Lucas performed extensive enocarcinomas and metastases have been described breakthrough studies in a large number of Egyptian in mummified tissues [6, 33-37]. Malignant neo- mummies which were the starting point of the scien- plasms are scarce in paleopathological studies, prob- tific development of the field of paleopathology [see ably due to a variety of causes including the absence 4, 5 for a review]. As mentioned previously, technical of chemical environmental contamination leading to developments such as the fixation methods by Ruffer less carcinogenic exposure, shorter life expectancy and Sandison, pioneer molecular approaches for or simply the disappearance of tissue evidence giv- the study of genetic material by Pääbo [26], the mul- en the frequent origin in and involvement of soft tidisciplinary approach to the study of the Tyrolean tissues [6, 36, 38, 39]. Contrarily to cancer, infectious Iceman [15, 16, 49], and similarly, well preserved 46 Paleopathology of soft tissues: what mummies can reveal subjects such as the Artic and bog mummies [2, 3. Buikstra JE, Cook DC, Bolhofner KL. Introduction: Scientific 52] have fuelled the extraction of a massive amount rigor in paleopathology. Int J Paleopathol 2017; 19: 80-87. 4. Aufderheide AC, Rodriguez-Martín C. History of Paleopathol- of relevant information from paleopathological proj- ogy. In: Aufderheide AC, Rodriguez-Martín C (eds.). The Cam- ects on “commoners”. bridge encyclopaedia of Human Paleopathology. Cambridge There have been important medical discoveries University Press, Cambridge 1998; 1-7. in subjects of historical relevance, usually from roy- 5. Aufderheide AC. History of mummy studies. In: Aufderheide al families. For instance, according to the micro- AC (ed.). The scientific study of mummies.Cambridge Univer- sity Press. Cambridge 2003; 1-17. scopic and molecular results provided by Marchetti 6. Lynnerup N. Mummies. Am J Phys Anthropol 2007; Suppl et al. [35], Ferrante I of Aragon, the King of Naples 45:162-190. during the XV century, most likely died of colorectal 7. Grauer A. A century of paleopathology. Am J Phys Anthropol cancer. Indeed, to our knowledge, this was the first 2018; 165: 904-914 bona fide molecular demonstration of a malignant 8. Ruffer MA. Pathological notes on the royal mummies of the Cairo museum. In: Studies in the Paleopathology neoplasm in an historical mummy. Similarly, the death of Egypt. Moodie RL (ed.). Univ. of Chicago Press, Chicago of Francesco I of Medici by malaria and the severe gout 1921; 166-178. of Emperor Charles V of Augsburg, most likely influ- 9. Sandison AT. The study of mummified and dried human tis- enced some historical events during the XVI centu- sues. In: Sciencie in Archeology. Brothwell D, Higgs E (eds.). ry [50, 53]. Indeed, it is within the context of the ca- London, Thames and Hudson, London 1963; 413-425. 10. Fornaciari G. Histology of ancient soft tissue tumours: A re- pacity of paleopathology to provide explanations view. 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