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

PREHISTORIC MULTIPLE MYELOMA DAN MORSE, M.D.

ResearchAssociate

R. C. DAILEY, Ph.D.

Associate Professor and Chairman JENNINGS BUNN

Department ofAnthropology 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

ex-tensive. It can involve all the bones of the skeleton but has predilection for the vertebrae, ribs, skull, andpelvis.2 3AccordingtoDahlin,2multiple

myeloma is the commonest primary malignant tumor of bone. In the Mayo Clinic series, myeloma accounted for 1,286, or 43%, of all malig-nant 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 aprecursor

to generalized distribution.2 3

Thetumor arises in the marrow spaces and invades the bone, leaving discrete rounded holes of various sizes. These holes have sharply

demar-catedborders which show little or nocondensation of bone.Gross speci-mens 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.

Clinicallythe diagnosis is confirmed by biopsy of the tumor. Archae-ologically a differential diagnosis would include first an osteolytic car-cinomatous metastasis. Discreteness of the individual lesions and exten-sive distribution favor myeloma. This is even more characteristic in

448 D. MORSE AND OTHERS

other conditions of the skeleton, such as osteitis fibrosa cystica,

histio-cytosis X, leukemia, and possiblyfibrous dysplasia.

In 1932 William Ritchie and Stafford Warren" reported a case of possible multiple myeloma in a prehistoric American Indian. This speci-men was derived from a "senile male" and was one of 43 skeletons excavated in 1930 from an Indian site near Binghamton, N.Y. Accord-ing 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 I2oo A.D. All the skeletal elements contained bone perforations ranging in size from 2 to I7 mm.

While examining skeletal material in the R. H. Lowie Museum of Anthropology, University of California, Berkeley, DonBrothwell called attention to multiple myeloma in a prehistoric California Indian. This

was reported by met in i969. According to information supplied by Dr. AlbertB. Elsasser, the skeleton, that of a female aged 45, was

exca-vated 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 osteo-lytic lesions of various sizes.

Inthe past few months the staffof 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

Fig. 1.Sowell Mound skull. Posterior view, showing large myelomatous lesion inoccipital

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

D. MORSE AND OTHERS co 0 P-ce 4o G._ Co 0o 04 ._ 4 50

and the closure of sutures, it is estimated that the individual was a male aged 45. There is alarge 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

meas-uring 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

di-ameter 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 evi-dence 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 islocated in an area occupied by the Naval Coastal Systems Laboratory

and has been so altered by recent developments that thesource ofwater

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 tobe 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 Creekand 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, frag-mented female skeleton consisting of a cranial vault, some fragments of

4 5 2 D. MORSE AND OTHERS

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skull and face, lower jaw, a few long bones,andsome piecesofribs, verte-brae, 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 degenera-tion, 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,

un-accompanied 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 accu-rately; apparently it belongs to the Late Mississippian Period, circa

1300 A.D.

Theburialin 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 labeledBurial

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

D. MORSE AND OTHERS 0 cq _ 04 i-4 454 A: A... He t-} X s # ,X,...e,,*t04 ... § ,.. ,7 4Boll -X if* 'ew .1. .j :A. :% A,%X I i6,,:.::,

the seventh cervical vertebra. This vertebra revealsthe 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, indi-cating nonpenetration of bone surface. Other vertebrae showing in-volvement, 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 thelumbar 2, 3, and

5.

Other bones affected include I I of the 34 rib fragments, the pelvis, and the right scapula.

SkullB (Figure 6) is that ofa female about 35 years old. The x ray shows manyareasofrarefactionof varied size; these appear tobe thesame asthose seen inmultiple myeloma. These are confined mostlyto the left parietal bone. These punched-out areas are not detected by simple inspec-tion. Thesurface of theouter table seemsnormal. On the inside there is a

large circular region of roughened superficial erosion. The lesion ap-pears 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

tumorcould 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.Anotherfeature not typical of myeloma is the build-up of osseous nodules on the borders. In addition, this skeleton

demon-stratesmarked generalized osteoporosis. The long bones are feather-light.

COMMENT

Four cases of possible prehistoric multiple myeloma are presented. Twoofthese, Calico Hills Burial One and Two, are so typicalin

appear-ance 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 mye-loma is still the best possibility. The Mangum Mound Case (Figure 6) is also most likely one of multiple myeloma, but the atypical lesion

onthe inside of the skull reduces confidence in the diagnosis.

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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 neces-sarily apply to other population groups.

Apreliminary report of this paper was read at the annual meetingof the American Association of Physical Anthropology held at Dallas,Tex., in May 1973. After the presentation several physical anthropologists stated that they had seen many similar cases (unreported) in their

pre-4 5 8 D. MORSE AND OTHERS

historic Indian collections. This leads one to the opinion that multiple myeloma in theprehistoric American Indian was not a great rarity.

REFERENCES

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. 23-29.

2. Dahlin, D. C.: Bone Tumors.

Spring-field,Ill.,Thomas, 1967, pp. 11, 124, 127. 3. Luck, J. V.: Bone and Joint Diseases.

Springfield, Ill., Thomas, 1950, p. 538. 4. Moore, C. B.: Certain aboriginal re-mains of the northwest Florida coast. J. Acad. Nat. Sci. 12:167-74, 1902.

5. Morse, D.: Ancient Disease in the Mid-west. Reports of Investigations, No.

1. Springfield, Ill., Illinois State Mu-seum, 1969, p. 144.

6. 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, 1932.

7. 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, 1941.