HISTORY Paleodermatoses: Lessons learned from mummies Eve Judith Lowenstein, MD, PhD Brooklyn, New York Mummies, the preserved remains of living beings from former times, bear witness across millennia to the maladies plaguing humankind. Disease, older than humanity, is better understood when examined in the context of history. Paleopathology, literally meaning “ancient suffering”, is the study of disease through evaluation of ancient remains. This area of increasing medical interest offers insights into the management of public health issues and disease epidemiology. This article provides an introduction and overview to paleodermatology, the branch of dermatology concerned with the evaluation of diseases associated with the integument by examination of ancient human remains. Mummy sources, how they were made and used throughout history, and the multidisciplinary approach used to study skin diseases found in mummies is briefly described. Despite pervasive pseudopathology, a remarkable array of diseases are well substantiated in the paleorecord, including infectious, heritable, nutritional, hormonal, acquired, iatrogenic, and neo- plastic disorders. Legitimate ethical concerns have been raised in the use of human remains for any purpose, with the lack of informed consent eliciting accusations of exploitation. While these studies are undertaken with certain risks, such as the acquisition of potentially dangerous or extinct infections, paleodermatology offers a unique and historical perspective on the afflictions of the skin and the way of all flesh. (J Am Acad Dermatol 2004;50:919-36.) “Far from being mute, ancient remains bear field offers information of medical and historical eloquent testimony to those who know how to significance. 1 listen.” Albert Kligman used the term “paleodermatol- A mummy is a human or animal corpse (soft ogy” to refer to anything done by dermatologists tissue and skeleton) preserved from decay, either before the advent of hydrocortisone.4 Iproposean naturally or artificially by embalming. The etymol- alternate definition. In line with the definition of ogy of mummy is something of a historical accident. paleopathology coined by the ‘father of modern 5 Early visitors to Egypt, observing mummies coated paleopathology’, Sir Marc Armand Ruffer, paleo- by a black, tarry resin, erroneously presumed that dermatology is the study of the integument and they were preserved by being dipped into pitch.2 associated diseases as demonstrated in the re- The Persian word mummia, signifying wax, pitch, mains of former times. One might arguably extend or bitumen, was thus ascribed.3 While mummies this definition to include literary and artistic sub- have been in existence for thousands of years, and stantiation of disease in former times. Such evi- dence, however, is indirect and less reliable, and certainly humans have been digging them up for therefore, not the subject of this article. Here re- almost as long, most of the scientifically valuable viewed are published findings relevant to paleo- information derived from mummies have been ac- dermatology. crued in the last century. Paleomedicine (palaios is Greek for old) is the medical field of observation through evaluation of ancient human remains. This WHY STUDY MUMMIES? While mummies have always attracted public at- tention, writing about mummies is hardly a sound From the Department of Dermatology, SUNY Health Science tactic for a young dermatologist trying to build a Center at Brooklyn. Supported by a Research Fellowship from the Research Foundation clinical practice or garner academic grants. Still, of the SUNY Health Science Center at Brooklyn. “. .the nature of diseases prevalent thousands of Conflicts of interest: None identified. years ago. .is not solely of academic interest, but is Reprint requests: Eve J. Lowenstein, MD, PhD, 450 Clarkson Ave, of practical importance, for in many instances the Box #46, Brooklyn, NY 11203. E-mail: [email protected]. eradication of disease may not be achieved until the Published online March 24, 2004. 6 0190-9622/$30.00 way in which it evolved has been determined.” © 2004 by the American Academy of Dermatology, Inc. Through studies of preserved remains, insight has doi:10.1016/S0190-9622(03)00914-9 been gained into the management of public health 919 920 Lowenstein JAM ACAD DERMATOL JUNE 2004 issues, disease epidemiology, and medical practices tion. Thus, a dermatologist’s perspective on paleo- of the past. For instance, the paleo-record attests to dermatologic findings is helpful. the prevalence of bilharzia in ancient Egypt, with One cannot discuss the value of paleomedical coprolites (mineralized feces) containing Schisto- studies without considering the ethical pitfalls in- soma hematobium larvae and eggs recovered from volved in the study of mummies. This issue has mummified human corpses and cesspits dating back received only cursory attention in the medical liter- over 3,000 years.7 With the institution of modern ature, with the rights and access to ancient materials irrigation upon the building of the first Aswan Low remaining a source of controversy.18 Recent legisla- Dam in 1902, an expanded habitat for the freshwater tion, such as the Native American Graves Protection snail vector of schistosomiasis resulted in an epi- and Reparation Act in 1990, resulted in a dramatic demic.8 Another bilharzia epidemic was experi- tapering off of human remains exhibits.19 This, how- enced upon the building of the second Aswan High ever, fueled further controversy, with accusations of Dam, with Schistosoma mansoni, more pathogenic an apparent double standard at the many American to humans, becoming dominant since the 1960s.9,10 museums continuing to exhibit human remains from Similarly, the paleorecord confirms that land clear- elsewhere.19 Universities sensitized about these is- ance for agricultural use and dense human settle- sues have in some cases re-interred bodies. While ments produced an environment favorable to the paleopathologists argue the potential health benefits Anopheles mosquito, vector for Plasmodium falci- from this research, scientists have not always shown parum, resulting in an increase in malaria in en- due respect in handling human remains, with re- demic areas.11 Understanding the historical patterns ports of body parts being used crudely as souvenirs of these diseases might help to predict and prevent even in our modern day.1 Media humor reflects this, outbreaks. with former President Clinton’s comments about the Paleoepidemiologic data have also been gathered well-preserved remains of Juanita (a sacrificed Inca on the effects of industrialization on public health. girl) that if he were single, he “might ask that In a study of 273 mummies from an upper class mummy out.”19 The Egyptians imposed great impor- population of ancient Egypt’s New Kingdom period tance on their bodies. Can the knowledge acquired (1550-1000 BC) found in the Tomb of the Nobles, through these studies offer sufficient “benefits” to researchers noted an increased incidence (com- justify the intentional disregard of the wishes of pared with modern day rates) of premature death, these ancient peoples? Any societal benefits and chronic disease, infection, dental caries, and acci- ‘literary immortality’ obtained through these studies dental and violent trauma, especially in females.12 of human remains may seem to us a worthwhile Finally, mummified remains harbor evidence of an- compromise, but may be completely antithetical to cient medicinal and surgical skills, such as the the wishes of the deceased. greatly lauded skills of ancient Egypt, the knowl- Beyond ethical concerns, the study of mummies edge of which might enlighten us even in our mod- may actually pose a health risk to society. Such ern day.13 Thus, by studying our past, we may learn concerns, for instance, of the potential risk posed in from our mistakes and strive to improve the future of working with tissue containing live tubercle bacilli humanity. For, as was most poignantly stated: have limited studies of pre-Columbian mum- “Those who cannot remember the past are con- mies.20,21 These concerns are further explored in the demned to repeat it.”14 discussion of smallpox. Paleopathology relies on a multidisciplinary ap- Mummies have been classified as accidental, in- proach. Dermatology offers unique insights in eval- tentional, or artificial.22 Accidental mummification uating paleopathologic findings. For instance, the involves the unexpected mummification of remains many blackheads on the face of Ramses II are not as a result of nature’s chance circumstances, such as likely to be an indication of his dislike for washing,15 heat, cold, or chemical soil composition. Intentional but rather a manifestation of chronic sun damage. mummification involves the purposeful preservation Similarly, the 34 cm horn found overlying a 2.5 cm of human remains by enhancing natural processes parietal bone defect obtained from a 74-year-old involved in the mummification. Artificial mummifi- woman’s remains is not likely to be a burst seba- cation involves purposeful preservation of remains ceous cyst,16 but rather, a large neglected squamous by unnatural means, including embalming or the cell carcinoma. Likewise, the suggested diagnosis of emersion in preservative fluids. Successful preserva- Sneddon-Wilkinson’s disease based on histopatho- tion of a mummy is not dependent on its age, but logic findings of neutrophilic pustules on an Egyp- rather depends on the growth of bacteria and fungi, tian mummy17 disregards more likely