American Journal of Physical Anthropology Volume 89 Issue 3 1992 [Doi 10.1002%2Fajpa.1330890306] Dr. Jean E. Aaron; Juliet Rogers; John a. Kanis -- Paleohistology of Paget's Disease

7/25/2019 American Journal of Physical Anthropology Volume 89 Issue 3 1992 [Doi 10.1002%2Fajpa.1330890306] Dr. Jean E. Aaron; Juliet Rogers; John a. Kanis -- P

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AMERICAN

JOURNAL

OF PHYSICAL ANTHROPOLOGY 89325-331 19921

Paleohistology

of

Pagets Disease in

Two

Medieval Skeletons

JEA N E. AARON, JULIE T ROGERS,

AND JOHN A. KANIS

Department of Hu m an Metabolism Medical School Universi ty of

Sheffield Sheffield SlO 2RX, England J.E.A., J.A.K.) and Department o

Medicine University of Bristo l B ristol Royal Inf irm ary

Bristol BS2 SHW, England J.R.1

KEY W O R D S

Paleopathology, Bone histology, Pagets disease

ABSTRACT Pagets disease has beer, ascribed several times

t o

specimens

of archeological bone but, in the absence of microscopic examination, the

evidence remains insubstantial. Suspected metabolic bone disease is de-

scribed here in the archeological remains of a skeleton from a 16th century

burial ground at Wells Cathedral, England and from a single medieval

sacrum recovered from a large deposit of disarticulated bones from a church-

yard at Barton-on-Humber, England. Radiographs showed apparent struc-

tural abnormality in one femoral shaft and calcaneus and in the isolated

sacrum. Histomorphometry on undecalcified bone cores confirmed the regions

of abnormality and showed not only increased trabecular width but also areas

of mosaic woven bone together with extensive resorption cavities; these

features contrasted with the normal structure and organized lamellar bone

from sites elsewhere. Despite post-interment changes in surrounding tissues,

the morphological stability of some of the osteocytes was remarkable. Preser-

vation of the histology was sufficient

t o

permit the assignment of a metabolic

bone disorder and the nature of the sclerosis was consistent with Pagets

disease.

992

Wiley-Liss,

Inc.

Although Pagets disease was recognised

as a clinical condition only one hundred

years ago, there are reports describing the

existence from neolithic times (Denniger,

Optical comparison with contemporary nor-

mal and pathological material is also made.

MATERIALS AND M ETHODS

1933; Wells and Woodhouse, 19753. How-

ever, it is generally acknowledged that

much of the evidence is fragmentary and

ambiguous, lacking histological confirma-

tion, and regularly attributing an occur-

rence where it is either geographically or

ethnically unlikely (Kanis, 1991).A s prepar-

ative techniques for undecalcified bone his-

tology have improved,

so

the use of the small

trephine sample

for

the optical microscopy

of ancient skeletal remains has increased

(Smith et al., 1981; Stout and Teitelbaum,

1976a,b; Stout, 1978; Weinstein et al.,

1981). By applying histological techniques

this communication seeks

to

add the dimen-

sion

of

microscopy

t o

the gross structural

information derived from the archeological

remains of two abnormal medieval skele-

tons with suspected metabolic bone disease.

The skeletal remains, from two individu-

als, consisted of the lower half of the male

skeleton (SK270), probably aged over

45

years, discovered in

a

16th century grave in

an excavated burial ground at Wells Cathe-

dral and an isolated medieval sacrum recov-

ered from large deposits of disarticulated

bone, from a churchyard excavation at Bar-

ton-on-Humber, South Humberside. Mor-

phological changes were evident; for exam-

ple, the left femoral shaft was enlarged and

the surface texture of the right and left cal-

canei differed. Radiographs were prepared

Received October 22,1991: accepted May 4,1992.

Address correspondence to Dr. J

E.

Aaron, Department of

Anatomy, Medical and Dental Building, University of Leeds,

Leeds LS2 9JT. England.

992 WILEY-LISS. INC


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326 J E

AAROI

of the individual bones and sites of apparent

abnormality identified. Using a bone biopsy

trephine, 8m m in diameter, cylinders of

bone were removed from the representative

radiologically normal and abnormal sites,

including the left and right 0s calces and the

sacrum. By means of established prepara-

tive techniques (for example, Aaron, 1976)

the specimens were dehydrated in alcohol,

embedded in methylmethacrylate and unde-

calcified sections,

8

pm thick, were cut us-

ing

a

heavy d u b Jung

K

microtome. Sec

tions were stained by the Goldner method

(Schenk et al., 19691,

o r

in 0.1 toluidine

blue stain, pH 3.5, or according

t o

the von

Kossa technique for bone mineral and pre-

pared for microscopy. The sections were ex-

amined in both plain and polarised light.

Using established histomorphometric proce-

dures (Aaron et al., 19871, the trabecular

width,

pm,

and the extent

of

resorption cav-

ities relative to the total trabecular bone

surface ( eroded surface) were determined.

Comparisons were also made with contem-

porary specimens

of

trabecular bone from

the 0s calcis and the iliac crest (the standard

clinical bone biopsy site) from subjects

whose bone status had been reliably diag-

nosed at autopsy or during attendance at

bone clinics.

RESULTS

While radiographs of much of the skeletal

remains appeared normal, X-rays of the

right calcaneus, enlarged left femoral shaft,

and parts of the sacrum appeared abnor-

mally dense and exceptionally coarse trabe-

culae were evident. The remaining and ap-

parently normal calcaneus functioned as a

control for its abnormal partner (Fig. 1).The

biopsy specimen from the unaffected calca-

neus remained intact, providing good con-

trol material (Fig. 2a). In contrast, the spec-

imen taken from the affected calcaneus

tended to fragment upon removal and its

fragility meant that particular care was re-

quired during processing (Fig. 2b). However,

the structure of the sacral specimen was bet-

ter preserved (Fig. 2c), although its normal

counterpart was poor. Comparison of the

16th century bone with contemporary mate-

rial showed a close similarity in the normal

trabecular architecture (Fig. 3a) and a gen-

\J

ET

AL.

Fig.

1

Radiographs of the sixteenth century

os

cal-

ces showing the dense and thickened trabecular struc-

ture on one side only.

era1 resemblance of the sclerotic pathologi-

cal regions to pagetic bone (Fig. 3b).

The inspection of the sections for possible

non-physiological post-mortem changes in-

dicated th at some demineralization, evident

with the Goldner and von Kossa stains, had

taken place (Fig. 4a). There was also evi-

dence of a reticulated pattern of destruction

within the bone matrix which seemed to

arise by the specific removal

of

exposed or-

ganic matrix and which some authors have

attributed to past fungal invasion (Stout

and Teitelbaum. 197613: Fig. 4b). In conse-

quence of these changes, asteoid tissue could

not be reliably identified. The material re-

moved from radiologically normal sites was

well-preserved, and in polarised light an

undisturbed lamellar organization was ob-

served (Fig. 5a). In specimens from the ap-

parently abnormal calcaneus and sacrum,

the trabeculae were grossly thickened and

although they were continuous (in contrast

with osteoporotic tissue) they contained a

substantial complement of disorganized or

woven bone (Fig. 5b). In addition, traces

of

convoluted cement lines which define the

mosaicbone pathognomonic of Pagets dis-

ease were clearly evident (Fig. 5b). At the

same time, deep and well-defined resorption

cavities were extensive (Fig. 5c). Moreover,

a small proportion appeared to contain large

cells closely juxtaposed

t o

Howships lacu-

nae and osteoclast-like in profile, though


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PALEOHISTOLOGYO F PA G E T S DISEASE

327

Fig. 2. Undecalcified histological sections showing Fig.

3 .

Undecalcified histological sections showing

the trabecular microanatomy of twentieth century bone

of established etiology. a Normal

0s

calcis, similar in

structure t o 2a.

b

Bone from the iliac crest of a patient

with Pagets disease showing the typical thick and irreg-

ular trabeculae, similar in str ucture to

2b

and c Tolu-

idine blue stain,

x

10.

the trabecular microanatomy of the sixteenth century

bone. a) Normal

0s

calcis. b Abnormal

0s

calcis with

thick and irre gular trabeculae; fragile trabecular cores

(arrowed) were lost during preparation but their pro-

files were retained by the embedding medium.c Abnor-

ma1 bone from the sacrum with intac t thick an d irregu-

lar trabeculae. Toluidine blue stain , x 10.

throughout both normal and pathological re-

cellular detail could not be resolved (Fig. gions and fine details

of

the fibrous nature

5c,d). Fragments of marrow tissue (Stout of the collagenous extracellular matrix at

and Teitelbaum, 197613) adhered to some

of

their periphery was still apparent (Fig. 5e).

the bone surfaces (Fig. 5a) although the Some osteocyte lacunae, together with their

marrow cavities were largely empty. Osteo- canaliculi, were unusually large and had

cyte lacunae were distributed regularly, probably been subjected to processes of at -


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328

J.E. AARON

T

AL.

Fig.

4

Non-physiologicalchanges in the sixteenth century bone. a) Sharply defined irregular areas of

demineralization (arrows); von Kossa stain, x 50.

b

A trabecula exhibiting a reticulated mineralized

matrix (arrow) surrounding clear areas

of

attrition. Goldner stain,

x

375

trition due to diagenic changes (Bell, 1990)

during prolonged interment (Fig. 6). While

many lacunae were devoid of cells, others

contained osteocytes in a remarkable state

of preservation with nuclei and fine cellular

processes remaining structurally intact

(Figs. 5e, 6). The quantitative analysis is

summarised in Fig. 7.

DISCUSSION

Pagets disease occurs in Western races

after the age of forty. It may be localized in

any part of the skeleton including the long

bones and sacrum and in more severe cases

there is bone enlargement and deformity.

The application

of

bone histology

t o

ancient

bones provides information which is not re-

solved by non-invasive procedures. In conse-

quence, a more reliable diagnosis of sus-

pected metabolic bone disease might be

anticipated (Bell and Jones, 1991; Wein-

stein et al., 1981).An important histological

feature which could not be assessed here

was the status of the osteoid tissue; this was

due t o non-physiological mineral density

gradations evident in some regions. Also, it

has been reported tha t unmineralized bone

matrix o r osteoid tissue is rarely, if ever,

preserved (Stout, 1978). Collagen is essen-

tially protected from degradation by the

mineral component of the matrix, the geo-

metric structure

of

which is unchanged by

fossilization and replacement with fluorides

and carbonates (Posner, 1969). The conser-

vation of collagen by bone salt is

so

effective

that the typical 640A periodic banding of

collagen has been observed in the electron

microscope in Pleistocene bones (see As-

cenzi, 1955 and Stout, 1978 for references).

Within this context the fine fibrous nature

of the collagenous matrix described above is

not unusual.

A t

the same time, it may be

because of the protective property of the

bone salt tha t a proportion of the bone cell

population was unexpectedly conserved.

Both osteocytes and osteoclasts contain

bone mineral during their life cycle. This to-

gether with their encapsulation within inac-

cessible bony cavities and lacunae may have

sufficed t o ensure tha t some escaped the de-

terioration and loss apparent in the nearby

marrow cells.

Pagets disease is probably most reliably

recognised histologically in bone

if

its char-

acteristic mosaic pattern can be detected

using polarised light. This feature, the re-

sult of deep resorption cavities on the one

hand and exuberant woven bone apposition

on the other, has been described as particu-

larly vulnerable to the pressure of long

burial (Putschar, 1966). However, Stout

(1978) refutes this with descriptions of wo-

ven bone as generally well preserved in the

ancient skeleton. This view is confirmed by

the persistence of mosaic bone, described

above. It follows that , while a number

of os-

teopathies such as osteogenic sarcoma

(sometimes a complication of Pagets dis-


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PALEOHISTOLOGY OF PAGETS DISEASE

3 9

Fig. 5. Histology of the sixteenth century bone.

a

Normal 0s calcis showing th e lamellar organization and

remnants of marrow tissue (arrow)adhering to trabecu-

lar surfaces. Polarised light; toluidine blue stain, x 125.

b

Abnormal

0s

calcis showing disorganized woven bone

with the sites of convoluted cement lines (arrows)outlin-

ing the areas

of

mosaicbone. Polarised light; tolnidine

blue stain, x 75.

c

and

d

Abnormal

0s

calcis showing

woven bone, resorption cavities (small arrow heads),

and osteoclasts (large arrows). Goldner stai n,

x

100 and

200, respectively. f Abnormal

s

calcis showing osteo-

cyte lacunae (large arrows) and bundles

of

exposed colla-

gen fibres (small arrow head) in the extracellular ma-

trix. Toluidine blue stain , x 480.


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330

J.E. AARON ET

AL

Trabecular width micron )

400

Fig. 6.

Osteocyte lacunae in sixteenth century bone.

Some osteocyte lacunae (Oc) were occupied by well pre-

served osteocytes with

a

nucleus (diagonal arrow) and

fine cell processes (horizontal arrow). The canaliculi

(Ca)were enlarged. Toluidine blue stain, x 850.

ease; Nordin 1973) and osteoblastic me-

tastases may share similar sclerotic histol-

ogy,

only one condition apparently presents

with thick trabeculae of mosaic bone in the

adult male On the basis of the thick and

irregular trabecular structure the deeply

defined resorption cavities the significant

areas of mosaic woven bone the discontin-

uous and localized nature of the abnormal-

ity and the favourable comparison with con-

temporary pathological preparations it is

concluded that the bone disease manifest in

these medieval remains is Pagets disease.

This may be the first incidence of Pagets

disease to be assigned histologically since

even one of the most reliable studies that of

Wells and Woodhouse (1975), acks any his-

tological confirmation of the proposed condi-

tion.

ACKNOWLEDGMENT

We are indebted to Monique Beneton for

histological preparation. The support of the

Eroded surface

(

bone surface)

s

calcis

0 s

calcis Sacrum Sacrum

Fig. 7. Histomorphometry of sixteenth century bone

comparing the trabecular width in pathological and nor-

mal regions and the exten t of resorption cavities. The

resul ts are th e mean one standard error. (Copyright

Dr. J . A. Kanis.)

i 3Normal bone on X-ray; Abnormal bone on X-ray

Medical Research Council PG 8600806)

is

gratefully acknowledged.

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Aaron J E (1976) Laboratory methods. In BEC Nordin

(ed.): Calcium, Phosphate and Magnesium Metabo-

lism. Edinburgh: Churchill Livingstone, pp. 564-567.

Aaron JE , Makins NB, and Sagreiya K (1987) Micro-

anatomy of tr abecu lar bone loss in normal aging men

and women. Clin. Orthop. 215t260-271.

Ascenzi A (1955) Some histochemical properties of or-

ganic substance in Neanderthal bone. Am. J. Phys.

Anthropol. 23r557-566.

Bell

LS (1990)Paleopathology and diagenesis.

An SEM

evaluation of str uctur al changes using back scattered

electron imaging. J . Arch. Sci.

17:85 102.

Bell LS, and Jones

SJ

(1991) Macroscopic and micro-

scopic evaluation of archeological and pathological

bone: Back scattered electron imaging of putative pag-

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J

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Kanis JA (19911Pathophysiology and Treatment of Pag-

ets Diseaes of Bone. London: Mart in Dunitz.

Nordin BEC (1973) Metabolic Bone and Stone Disease.

Edinburgh: Churchill Livingstone.

Posner AS (1969) Crystal chemistry of bone mineral.

Physiol. Rev. 49t760-792.

Putschar WGJ (1966) Problems in th e paleopathology of

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Jarcho

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Human Paleopathology. New

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trends in humeral cortical thickness of near easter n

populations. J. Human Evol. 13:603-611.

Stout SD (1978) Histological struc ture and its preserva-

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SD,

and Teitelbaum

SL

(1976a) Histomorphomet-

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Documents

American Journal of Physical Anthropology Volume 89 Issue 3 1992 [Doi 10.1002%2Fajpa.1330890306] Dr. Jean E. Aaron; Juliet Rogers; John a. Kanis -- Paleohistology of Paget's Disease