Skeletal metastatic carcinomas from the Roman period (1st to 5th Century AD) in Hungary

OBJECTIVES

According to paleopathological records, tumors have a great antiquity. The prevalence of cancer in ancient populations might have differed from that in modern humans because of substantial differences in environmental factors, life expectancy and the availability of treatment. This study presents 3 cases of probable skeletal metastatic carcinoma from the Roman period (1st-5th century AD) in Hungary, showing the development of bone metastases of cancer without chemo- and radiotherapy.

METHODS

All skeletons were subjected to a careful macroscopic investigation, which was extended by radiological, stereo- and scanning electron microscopic analyses.

RESULTS

In 1 case, the mixed nature and localization of the lesions, as well as the sex and age of the individual, suggested breast cancer as the primary focus. In the other 2 cases, based on the mostly osteoblastic nature and the localization of the lesions as well as on the sex and age of the individuals, the most probable diagnostic option is prostate carcinoma with skeletal metastases.

CONCLUSIONS

In view of the scarcity of cancer metastases that have been diagnosed in archeological specimens in general, identification of all examples of cancer in antiquity represents an important contribution both to paleopathology and to modern medicine.

[The establishment of the hospital-system in the Byzantine Empire]

Byzantine hospitals developed out of Christian institutions for the poor and homeless. Philanthropy provided the initial impulse to create hospices (xenons) and to expand these institutions into specialized medical centers (iatreons or nosokomeions). However the Byzantine nosocomeions resemble more closely modern hospitals than they do any of the institutions of Greek-Roman antiquity or any of the houses of charity in the Latin West during the Middle Ages. Since the 4th century the Byzantine hospitals have stressed the central position of the nosocomeion in Byzantine society at the intersection of state, ecclesiastical and professional interest. In the great cities and in the capital, more than hundred hospitals worked in the East-Roman Empire. The Byzantine hospital rules guaranted patients private beds, required physicians to wash their hands after each examination and arranged the physical plant to keep all the sick warm. The Byzantine hospitals had separate sections (in modern terms: surgery-trauma surgery, internal medicine, ophthalmology, etc.) and at the beginning of the sixth century a separate institution for women. From the sixth century at least, bathing facilities normally adjoined Byzantine nosocomeia. By the twelfth century Byzantine hospitals also set aside a room or perhaps a separate building to treat outpatients. In addition to the main dormitories the surgery, baths and outpatient clinic, the large parts of hospitals also had separate rooms (or adjoining buildings) for library, for lecture hall, for administrative functions and record keeping for storage and for other services.

[Magical and religious healing in Byzantium]

Religious and magical ways of healing have been known and practiced since the very beginning of human history. In the present article, the Byzantine philosophical, cultural, historical and "methodological" aspects of this way of healing are discussed. The article outlines the development of magic healing in Byzantium from the 4th to the 15th century. During this period magical therapy included the cult of patron saints--listed by the author--and pleading for divine intervention as well. The activity of "anargyroi" and the use of magical objects and amulets is also discussed in detail. Exorcism was also a part of religious therapy both against psychical and somatical diseases. In early Christianity, and especially in Byzantium the devil or other demons were also supposed to cause various somatical or psychical illnesses by "intrusion" or "internalisation," i.e. by possession or obsession of their victims.

[Dental care, dental diseases and dentistry in antiquity]

Numerous written relicts, belletristic works (poems of Martial, Juvenal, Ovid etc.) indicate that oral hygiene and its tools (toothbrush, toothpick, use of tooth pastes and tooth-powder) were used long before our times. Already ancient people started to remove, file, dye and inlay teeth. The teeth were dyed red, green or black in Egypt, red or brown (with henna or betel) in India, white by Romans. The teeth decoration has a long but forgotten history. The most skillful and artistic work was done by the Maya's between 900 BC and 1500 AD. The modification of contours (more than fifty forms) of the incisors were practiced also in Mesoamerica. Dentistry was surely practiced in ancient Egypt, India, China, Greece and Rome, while odontology and especially suitable dental appliances arose only by Etruscan. Dental prosthesis, including bridges and simple retention bands were invented by the Etruscans 2500 years ago. These Etruscan bridges were worn mostly by females, suggesting that cosmetics was the principal dental concern. Some,--if not all--of the Roman and other prostheses have been purely ornamental. Orthodontic appliances are also Etruscan invention. The holes caused by caries were filled with garlic, incense, caraway seed in Egypt, with wood or lead in Rome, and with "silver-paste" (amalgam) in ancient China. The toothache was cured with poppy-tee, or hashish and nightshade plants (Solanaceae) in Egypt, Greece, Roman Empire while with coca (Erythroxylon coca) in South-America.

[Obesity in sculptures of the paleolithic era]

In this paper I present 100 neolithic figurines (97 female and 3 male) made of ivory, mammuth bone, limestone and other substances. The sculptures were found on the Eurasian continent, from the Pirenees to Lake Baikal and the river Amur. More than half (57.3%) of the idols show various types of female obesity. However, they are named ironically "Venus"-es. The figurines are described and speculation underlying the reason for such depictions and their uses are presented.

Fragile external phenotype of modern human proximal femur in comparison with medieval bone

Proximal femur macroanatomy of 118 medieval and 67 contemporary adults, 84 contemporary elderly, and 48 contemporary hip fracture cases was evaluated. Within approximately 1000 years, the femoral neck axis has become longer, and its cross-section has become proportionally smaller and more oval in shape. These changes in the present external phenotype alone account for approximately 50% higher fall-induced stress compared with the medieval situation.

INTRODUCTION

Bones, as whole skeletal structures, adapt to mechanical stresses they customarily experience. Because the present, mechanized lifestyle apparently deprives our skeletons of vigorous, habitual physical exertion, we studied whether the proximal femur phenotype has evolved vulnerable to fragility fractures by time.

MATERIALS AND METHODS

Proximal femur macroanatomy of 118 medieval and 67 contemporary adults, 84 contemporary elderly, and 48 contemporary hip fracture cases was evaluated. Using direct measurements of external bone dimensions and geometric properties, we estimated the fall-induced stress as an index of hip fragility.

RESULTS

Within approximately 1000 years, the femoral axis length has become substantially longer (analysis of covariance, body height adjusted, p < 0.001), whereas the neck circumference has not increased. The macroanatomy was found similar between the contemporary adult and elderly groups. In hip fracture cases, however, the femoral axis length was further lengthened (p < 0.001), but the circumference was somewhat smaller (p = 0.001). Consequently, the estimated fall-induced stress can be approximately 1.5-fold today compared with the medieval times (p < 0.001), and the secular trend seemed to be worse in women (sex-time interaction, p = 0.001).

CONCLUSIONS

The modern, relatively slender phenotype of the proximal femur alone seems to increase the fall-induced stress considerably, and when this phenotype coincides the osteoporotic, internally deteriorated femoral neck structure, fracture risk is imminent. This mechanically compromised external phenotype underscores the importance of timely strengthening of the skeleton and its regular maintenance throughout life.

[Cripples at the medieval hospital of Bátmonostor, Hungary--archeological findings]

Cripples from the medieval hospital of Bátmonostor, Hungary. People with disabilities were generally burdened with a painful fate in ancient times, however in the hospitals was no effective therapy. The hospital of Batmonostor was founded at late 13th century, The authors examine by morphological, radiological and histological methods 426 complete skeletons excavated from medieval (14th-15th century) cemetery of Bátmonostor (Hungary). Among them 30 cases (7.1%) of bony ankylosis, (24 cases on lower limb and 6 cases on upper limb) was found. Sacroiliac ankylosis 3 cases, Bechterew's spondylitis ankylopoetica 1 case was seen. Spondylitis tuberculosa and malum Potti 4 cases, and hunchback with other aetiology 2 cases was detected. Beside the cases with ankylosis severe posttraumatic osteomyelitis (7 cases), primary malignant bone tumors (2 cases) and an osteoplastic metastatic tumors (probably prostata carcinoma) was diagnosed. Paleopathologic study of the physically disabled may yield information and insight on the prevalence of crippling disorders. The authors hypothetize, that crippled persons lived in the hospital until their deaths.

Collagen fibres of the spontaneously ruptured human tendons display decreased thickness and crimp angle

PURPOSE

To study collagen fibre thickness and crimp formation in healthy and ruptured human tendons.

METHODS

The thickness, crimp angle and wavelength of the collagen fibres were analyzed by interference and polarization microscopy and the samples were studied by transmission and scanning electron microscopy in four different healthy human tendons (Achilles, Quadriceps, Biceps brachii and Extensor pollicis longus) and in 66 spontaneously ruptured tendons.

RESULTS

In the normal (healthy) tendons, the diameter and crimp angle of the collagen fibres varied greatly between the four different tendons, the thickest fibres with the largest crimp angle being in the Achilles and Quadriceps tendons, whereas the Biceps brachii and Extensor pollicis longus, tendons that bear lighter strains but carry functions of high specificity, were found to have substantially smaller collagen fibres with lower crimp angle. Ruptured tendons had significantly smaller collagen fibre diameter than the normal tendons, the fibre diameter being -36% in comparison to their healthy counterparts in the Achilles tendons (P < 0.0001), -24% in the Quadriceps tendons (P < 0.0001), -37% in the Biceps brachii (P < 0.0001) and -14% in the Extensor pollicis longus (P = 0.10), respectively. Similarly, the crimp angle of the collagen fibres was also found to be lower in the ruptured tendons than in healthy, normal tendons. Further, the collagen fibres in the ruptured human tendons showed great variation in the crimp angle between the adjacent fibres and in the successive crimps of the same fibre.

CONCLUSION

Our results show that spontaneously ruptured tendons display focal regions with decreased collagen fibre thickness, decreased crimp angle and disrupted crimp continuity, microscopic alterations that possibly result in reduced strength of the tendons being less resistant to tensile forces, and thus, place them at increased risk of ruptures.

[Ill-conditioned rules on the throne of Byzantium]

Author presents and analyses informations of non-medical texts of Byzantine historians and chroniclers concerning diseases of Byzantine emperors, concluding that diseases were implicated in certain political and military difficulties. Only one third of the emperors died due to natural causes (i.e. illnesses). Some historians, such as Anna Comnena and Michael Psellos had studied medicine, both of them had excellent knowledge of medical theories of their times. Some diseases in Byzantium were widespread and had high morbidity. This material gives an indication that arthritis (resembling gout) tyrannised a great number of emperors. Contemporary historians maintain that the main causes of gout were overconsumption of alcoholic drinks and food. Other very serious conditions were acute and chronic pyelonephritis and urolithiasis. Relatively frequent conditions of the emperors included pestilential diseases (dysentery, typhoid fever, etc.), psychiatric disorders, epilepsy and arteriosclerosis.

[Juxtacortical osteosarcoma of tibia from a medieval cemetery of Budapest]

Juxtacortical osteosarcoma occurred on the right tibia and fibula of a 20-22 years old man found in a medieval period cemetery of Budapest. MACROSCOPIC DESCRIPTION: The tumor is located circumferentially on the midshaft of the tibia and fibula and appears cone-shaped. The lesion measured 160 mm in length and 3-5 mm in height. The surface of the tumor is irregular, rough, in some areas shows spicules. These spicules averaged 2-4 mm in length and 1-2 mm in diameter. The anterior and medial surface of the tibia is completely covered by osseous tumor. RADIOGRAPHY: The X-ray study demonstrates the medullary involvement, with mixed osteolytic and osteoblastic areas. Tumor infiltration of the cortex is also apparent as irregular rarefication and lytic lesions. In some areas a "sunburst" picture could be seen. The X-ray picture is characteristic for juxtacortical osteosarcoma. MICROSCOPIC EXAMINATION: stereomicroscopy of specimens shows a sponge-like structure of the surface. The cortical bone is completely destroyed and deep cavities are seen between spiculous and gyrificated neoplastic bone. The spiculae are varied in length and thickness. Irregular bulky bone trabeculae demonstrating uncontrolled neoplastic reaction could be detected. By light microscopic examination severe destruction, osteolytic lesions are seen both in the cortical bone and in the cancellous bone in the peripheral parts of the tumors. Within the neoplastic bone only few remnants of the primary (normal) bone structure could be demonstrated. No reparative reactions were seen next to the osteolysis, the collagen fibers and lamellas are destroyed. Beside the destruction of original bone larger structures composed of irregular newly built nepotistic bone trabeculae can be detected. The newly formed trabeculae (spiculae) contain a tumorous ground substance (probably osteoid tissue) with few collagen fibers, and these areas are covered with a thin bony lamella. In some areas the neoplastic structures are in intimate contact with the original cancellous bone remnants. IMMUNOHISTOCHEMISTRY: Both the osteosarcoma and chondrosarcoma show osteoid and bone neoformation while in the chondrosarcoma type II collagen could also detected. By immunohistochemical reactions no type II and III collagen, only type I collagen reaction was positive. This means that no cartilaginous tissues were present in the tumor. Scanning electron microscopy of these specimens shows sponge-like structures. The tumor reveals irregular trabecular and spicular texture,the spicules are various in diameter and in some spiculae rounded deposits attached to the surface. In our case we found typical radiological and histological picture of the juxtacortical osteosarcoma.

Spiral cracks in drying precipitates

We investigate the formation of spiral crack patterns during the desiccation of thin layers of precipitates in contact with a substrate. This symmetry-breaking fracturing mode is found to arise naturally not from torsion forces but from a propagating stress front induced by the foldup of the fragments. We model their formation mechanism using a coarse-grain model for fragmentation and successfully reproduce the spiral cracks. Fittings of experimental and simulation data show that the spirals are logarithmic. Theoretical aspects of the logarithmic spirals are discussed. In particular we show that this occurs generally when the crack speed is proportional to the propagating speed of stress front.

Effects of remobilization on rat femur are dose-dependent

Seventy 9 to 11-week-old Sprague-Dawley male rats were divided into seven groups [baseline, 3-week, 11-week control groups; a group with a left limb immobilization for 3 weeks; and three groups with a similar immobilization and subsequent 8-week free (FR), low-intensity running (LR) or high-intensity running (HR) remobilization] to determine the site-specific effects of decreased mechanical loading and subsequent increased activity on rat femur. Bone mineral content of the proximal femur (PBMC), femoral midshaft (SBMC) and distal femur (DBMC) and the histomorphometry of the distal femur were used as outcome variables. The 3-week immobilization period resulted in significant bone loss in the proximal and distal ends of the immobilized left limb, the deficit being -5.9% in PBMC and -14.7% in DBMC. Immobilization also led to marked microarchitectural changes in the distal femur, the left-side deficit in trabecular bone volume (BV/TV) being -23.9%. After remobilization, there was a clear indication for dose-dependent response; i.e., immobilization-induced left-to-right side differences in BV/TV persisted in the FR animals (-23.8%), while these left limb deficits were significantly reduced in the LR group (-15.0%) and virtually absent in the HR group (-3.1%). The left limb deficit in PBMC was still significant in all groups after the 8-week period of remobilization [-9.6% in the FR group; -13.4% in the LR group; and -7.2% in the HR group]. The left-limb deficit in SBMC was significant in the HR11 group only (-7.2%), and, contrary to histomorphometric data, virtually absent in DBMC in all remobilization groups. As compared with the age-matched control data, the weight-adjusted BMCs of both limbs of the LR and HR groups were comparable or even higher (right limbs) than those of the controls. In conclusion, this study indicates that remobilization-induced bone recovery depends on the intensity of the remobilization so that during the 8-week period of remobilization, high-intensity running results in better recovery than low-intensity running, both of which are more efficient than free-cage activity only. Immobilization-induced changes in rat femur are also restored in a site-specific fashion, the most trabecular distal region of the femur showing more complete recovery than the more cortical proximal and midshaft regions.

Achilles tendon injuries

The Achilles tendon is the strongest tendon in the human body. Because most Achilles tendon injuries take place in sports and there has been an common upsurge in sporting activities, the number and incidence of the Achilles tendon overuse injuries and complete ruptures have increased in the industrialized countries during the last decades. The most common clinical diagnosis of Achilles overuse injuries is tendinopathy, which is characterized by a combination of pain and swelling in the Achilles tendon accompanied by impaired ability to perform strenuous activities. Most patients with Achilles tendon injury respond favorably to conservative treatment and only those who fail to respond to carefully followed nonoperative treatment should undergo surgery for repair. A complete rupture of the Achilles tendon usually occurs in sports that require jumping, running, and quick turns. Although histopathologic studies have shown that ruptured Achilles tendons include clear degenerative changes before the rupture, many of the Achilles tendon ruptures occur suddenly without any preceding signs or symptoms. Neither conservative nor operative treatment is a treatment of choice for the ruptured Achilles tendon. It is generally accepted that surgery should be performed on ruptured Achilles tendons in young, physically active patients and in those patients for whom the diagnosis or the treatment of the rupture has been delayed, whereas the results of conservative treatment are an acceptable outcome in older patients with sedentary lifestyles. Many important issues still remain unanswered concerning the cause, pathogenesis, diagnosis, and management of the Achilles tendon disorders. Only when these issues have been solved by well-controlled studies can tailored treatment protocols be created.

Blood flow in rat gastrocnemius muscle and Achilles tendon after Achilles tenotomy

The effect of Achilles tenotomy on resting blood flow of rat gastrocnemius muscle and Achilles tendon was studied by radioactive microspheres. Tenotomy produced an immediate, marked decrease in both intramuscular and intratendinous blood flow and it remained significantly lowered at both sites till the end of the observation period, i.e., day 18 after tenotomy. The decrease in the resting blood flow was more rapid and pronounced in the Achilles tendon than in the gastrocnemius muscle. Although the blood flow of the Achilles tendon started to recover after the 4th postoperative day, it was still 33% (statistically not significant) lower than that in the controls 18 days after tenotomy. In the gastrocnemius muscle, the 18-day deficit was 38% (p < 0.001), respectively. The results indicate that after division of a rat Achilles tendon the resting blood flow to the gastrocnemius muscle and Achilles tendon is not adequately restored, remaining at a significantly lowered level even 18 days after tenotomy.

[Microscopic study of dental calculus in cadavers from the 18th-19th centuries]

The authors studied the dental calculus of 20 mummies with ligth microscopy, polarized ligth microscopy and scanning electron microscopy. Gram positive bacteria could be detected in all preparates, while Gram negative bacteria in 12 and fungi only in 3 dental calculus was visible. Animal food remains within five, and plant remains in all dental calculus were identified. Anorgic element and cell debris were seen in all preparates.

Histopathological findings in chronic tendon disorders

Tendon injuries and other tendon disorders represent a common diagnostic and therapeutic challenge in sports medicine, resulting in chronic and long-lasting problems. Tissue degeneration is a common finding in many sports-related tendon complaints. In the great majority of spontaneous tendon ruptures, chronic degenerative changes are seen at the rupture site of the tendon (1). Systemic diseases and diseases specifically deteriorating the normal structure of the tendon (i.e. foreign bodies, and metabolic, inherited and infectious tendon diseases) are only rarely the cause of tendon pathology. Inherited diseases, such as various hereditary diseases with disturbed collagen metabolism and characteristic pathological structural alterations (Ehlers-Danlos syndrome, Marfani syndrome, homocystinuria (ochronosis)), represent approximately 1% of the causes of chronic tendon complaints (2), whereas foreign bodies are somewhat more common and are found in less than 10% of all chronic tendon problems (1). Rheumatoid arthritis and sarcoidosis are typical systemic diseases that cause chronic inflammation in tendon and peritendinous tissues. Altogether, these 'specific' disorders represented less than 2% of the pathological alterations found in the histological analysis of more than 1000 spontaneously ruptured tendons (1, 3, 4). In this material, degenerative changes were seen in a great majority of the tendons, indicating that a spontaneous tendon rupture is a typical clinical end-state manifestation of a degenerative process in the tendon tissue. The role of overuse in the pathogenesis of chronic tendon injuries and disorders is not completely understood. It has been speculated that when tendon is overused it becomes fatigued and loses its basal reparative ability, the repetitive microtraumatic processes thus overwhelming the ability of the tendon cells to repair the fiber damage. The intensive repetitive activity, which often is eccentric by nature, may lead to cumulative microtrauma which further weakens the collagen cross-linking, non-collagenous matrix, and vascular elements of the tendon. Overuse has also been speculated to cause chronic tendon problems, by disturbing the micro- and macrovasculature of the tendon and resulting in insufficiency in the local blood circulation. Decreased blood flow simultaneous with an increased activity may result in local tissue hypoxia, impaired nutrition and energy metabolism, and together these factors are likely to play an important role in the sequence of events leading to tendon degeneration (4). A sedentary lifestyle has been proposed as a main reason for poor basal circulation of the tendon, and presumably is at least partly responsible for the high number of tendon problems in people with a sedentary lifestyle who occasionally take part in high physical activity sports events.

Effects of training, immobilization and remobilization on tendons

Since a tendon is a living tissue, it is not a surprise that tendon shows the capacity to adapt its structure and mechanical properties to the functional demands of the entire muscle-tendon unit. However, compared with muscle, the experimental knowledge of the effects of strength or endurance-type training on tendon tissue is scarce and clinical human experiments are completely lacking (1). Research should, however, be able to improve the true understanding of the biomechanical, functional, morphological and biochemical changes that occur in tendons due to training and physical activity, since understanding of the basic physiology of a tissue is the key to understanding its pathological processes (1, 2). Compared with muscle tissue, the metabolic turnover of tendon tissue is many times slower due to poorer vascularity and circulation (1, 3). The adaptive responses of tendons to training are therefore also slower than those in muscles, but they may finally be considerable if the time frame is long enough (3, 4).

Histopathological findings in spontaneous tendon ruptures

A spontaneous rupture of a tendon may be defined as a rupture that occurs during movement and activity, that should not and usually does not damage the involved musculotendinous units (1). Spontaneous tendon ruptures were uncommon before the 1950s. Böhler found only 25 Achilles tendon ruptures in Wien between 1925 and 1948 (2). Mösender & Klatnek treated 20 Achilles tendon ruptures between 1953 and 1956, but 105 ruptures between 1964 and 1967 (3). Lawrence et al. found only 31 Achilles tendon ruptures in Boston during a period of 55 years (1900-1954) (4). During the recent decades tendon ruptures have, however, become relatively common in developed countries, especially in Europe and North America. A high incidence of tendon ruptures has been reported in Austria, Denmark, Finland, Germany. Hungary, Sweden, Switzerland and the USA; somewhat lower incidences have been reported in Canada, France, Great Britain and Spain. On the other hand, Greece, Japan, the Netherlands and Portugal have reported a clearly lower incidence. Interestingly, Achilles tendon ruptures are a rarity in developing countries, especially in Africa and East-Asia (5). In many developed countries, the increases in the rupture incidence have been dramatic. In the National Institute of Traumatology in Budapest, Hungary, the number of patients with an Achilles tendon rupture increased 285% in men and 500% in women between two successive 7-year periods, 1972-1978 and 1979-1985 (5).