168 • Jane E. Buikstra and Sloan Williams 



Summary and conclusions 



Recent years have seen several new and productive ap- 

 proaches to issues relating to the tuberculosis-like pathology 

 present among prehistoric human remains in the Americas. 

 The simulation modeling developed by McGrath suggests 

 that a pathogen behaving much like modem M. tuberculosis 

 could not have been maintained within certain North Ameri- 

 can prehistoric groups. In the face of skeletal evidence docu- 

 menting the presence of the disease in west-central Illinois, 

 we must consider the possibility that the pathogen responsi- 

 ble was not M. tuberculosis and that we are documenting a 

 host pathogen relationship not common in recent history. In 

 this case, McGrath's model based upon disease experience in 

 modem human groups would have been misspecified. 



Clark et al. (1987) have postulated an important role for 

 the "environmental mycobacteria" in explaining the expres- 

 sion of apparent tubercular disease. While we agree that in 

 isolated cases, the possibility that skeletal lesions resulting 

 from the atypical mycobacteria may mimic those caused by 

 M. tuberculosis, it is unlikely that the environmental patho- 

 gens were responsible for many of the tuberculosis-like le- 

 sions described for late prehistoric series. Certainly, as at 

 Moundville, it is possible that disease prevalence was influ- 

 enced by the presence of environmental mycobacteria. Fur- 

 ther investigations of geographic distributions for the my- 

 cobacteria and prevalence figures for ancient disease may, 

 therefore, prove instructive. 



Finally, we have described patteming for a tuberculosis- 

 like pathology in a large series of skeletons from southem 

 Peru. Although prior studies of Andean remains had de- 

 scribed an age-specific lesion pattern different from that re- 

 ported in North America, the Estuquina site series shows 

 strong similarity to their northern contemporaries. The 

 strong sex bias in the sample, however, remains problematic. 



In closing we would like to take issue with Clark et al.'s 

 (1987:58) assertion that "from the anthropological perspec- 

 tive, differential diagnosis is unproductive, at least when 

 adaptation and evolution are the primary foci." We must 

 engage in differential diagnosis, if we are to represent fully 

 and accurately the health status of prior human groups. Oth- 

 erwi.se we risk confusing the degenerative results of occupa- 

 tional stress with the products of trauma, the treponematoses 

 with fungal infections, the presence of widespread, epidemic 

 disease with the impact of environmental pathogens, and the 

 impact of nutritional imbalance with the results of infectious 

 processes. Without concern for differentiating disease forms, 

 we will at best obfuscate and at worst misrepresent the course 

 of human history. Differential diagnosis is no more an empty 

 exercise than theorizing without considering contradictory 

 empirical evidence. The study of human adaptation in the 

 past requires scientific methodology, including both theory 

 and data-based tests. As illustrated by the current controver- 

 sies surrounding prehistoric "tuberculosis" in the Americas, 

 differential diagnosis plays a crucial role in this process. 



Acknowledgments 



The research reported here was funded by the National Sci- 

 ence Foundation (BNS87- 17590), the Center for Latin Amer- 

 ican Studies, and the Lichtstem Fund of the Anthropology 

 Department at the University of Chicago. The content and 

 organization of the document has benefited immeasurably 

 from the criticism of Mary Powell and Lisa Leuschner. 



Appendix. Individuals with tuberculosis-like pathology 

 from Estuquina site 



M6-I8I : Sex unknown, 25-30 years. ResorpU\e areas on intemal 

 aspect of ribs. 



M6-336a: Male 39+ years. At time of death remodeling was active 

 in lumbar region. LI only slightly affected, with resorption on 

 inferior and lateral aspects of body. Much of this area does not show 

 sclerotic emargination . Superior aspect of L4 has a ca. 5-mm cavita- 

 tion with sclerotic emargination that appears to have recently 

 "broken through" to surface. Disk spaces in lumbar region and at 

 L5-S1 have been crossed by process. Anterior aspect of L2-S1 

 bodies also present periosteal proliferation. 



M6-771 : Child 2-3.25 years. Slight amount of light, pinpoint 

 cribra orbitalia is observable. Porotic hyperostosis appears on oc- 

 cipital, near lambdoid suture. All deciduous teeth show dark stain- 

 ing on buccal aspect near CEJ. Linear enamel hypoplasia present in 

 all incisors. 



Limb long bones show porosity, especially at metaphyses. as well 

 as remodeling in areas of tendon/ligament attachment. Both ilia 

 present unusual porosity on external surfaces. Sternum very porous, 

 especially the manubrium. 



Ribs show sclerotic raised areas on intemal aspect of bodies of 

 right ribs 9-12, esp. 1 1 . It is this pathology that has drawn M6-77 1 

 into the affected group, along with periosteal remodeling on exter- 

 nal aspects of ilia. Remodeling of limb long bones is subtle, not 

 fulminating onion-skin expansion noted in others from the Estu- 

 quina sample. 



Well-integrated remodeled diaphyseal bone and dental pigmenta- 

 tion suggest long-standing health problems for this individual. 



M6-I002: Male 17- 19 years. 7th thoracic unit shows a multilocular 

 resorptive area, without much obvious sclerotic emargination. 



M6-I02la: Female 45 + . Right scapula and humerus have con- 

 figuration that could be the result of a tubercular prcK-ess. If so, 

 onset occurred before individual was fully (skeletally) mature since 

 the disease seems to have caused resorption and dislocation of 

 humems head, which is fused to glenoid fossa of scapula. Glenoid 

 fossa surrounding this area shows focal lesions ca. 5-7 mm in 

 diameter, with sclerotic emargination. 



Spinal column heavily involved. There is an oval cavity on C6, 

 1.1 X 0.5 cm in diameter, into which C5 fits. Epiphyseal ring of C6 

 has formed a buttressing osteophyte, again suggesting long-term 

 pathology. This strut was sufficiently efficient that there was little 

 apparent loss of effective body height. 



T3; superior surface of body has collapsed into an intemal lesion, 

 which displays sclerotic emargination. 



Zagreb Paleopathology Symp. 1988 



