Vertebral tuberculosis in ancient Egypt and Nubia • 191 



DIAGNOSIS 



Comparing characteristic features of tuberculosis in case no. 

 2 with case no. 1 (Table 1), we find differences in more than 

 half of them. Case no. 1 findings indicated a long duration 

 with prevalence of adaptive changes and healing. In contrast 

 to this, case no. 2 showed a relatively short-term and active, 

 predominantly lytic process with very limited healing. 



At the same time, with half of the features there seems to 

 be a disagreement with the usual diagnostic set for tuber- 

 culosis. This applies first to the extraordinarily great extent 

 of the process, involving altogether 17 vertebrae with major 

 changes in four of them. From the recent literature two cases 

 with similarly elevated numbers of afflicted vertebrae can be 

 quoted. The first one from Oberweil bei Buhren a.d. Aare 

 (Switzerland), dated 7th-8th century a.d., was that of an 

 18-23-year-old woman afflicted by a destructive-reparative 

 process involving 13 vertebrae, C7 and all thoracic with 

 maximum changes between T4 and T6 (Ulrich-Bochsler et 

 al. 1982:1318-1319). A juvenile male aged about 15 years 

 from Arene Candide Cave (Liguria, Italy), dated beginning 

 of the 4th millennium B.C., showed resorptive lesions in 

 eight vertebrae (T9-L4) with a maximum of destruction be- 

 tween TIO and LI (Formicola et al. 1987:3). Cases with a 

 great extent of the process most probably reflect the great 

 virulence of infection and the limited resistance of the host. 



In agreement with that we found the uncommon involve- 

 ment of anterior sections of the neural arch (pedicles and 

 articular processes) which characterizes very severe cases 

 (Zimmerman and Kelley 1982:105). 



Because the process was relatively rapid and destruction 

 dominated production of new bone, there was not enough 

 time and resistance for the development of fused vertebral 

 bodies, ossification of interspinous or lateral longitudinal 

 ligaments, apposition of new-formed bone, or fusion of cos- 

 tovertebral joints. Steady progression of the destruction over 

 healing was revealed especially in LI whose "healed" wedge 

 shape was eroded anew by suppuration. 



The process did not nartow the neural canal, but did in- 

 volve a single intervertebral opening. Absence of compensa- 

 tory growth of vertebrae was connected with the later begin- 

 ning of the disease and lack of emaciation together with its 

 relatively short duration. 



psoas abscesses is attested by the bilateral development of the 

 demarcated iliac periostitis. The patient did not develop 

 enough resistance and the infection spread both in the cranial 

 and caudal directions gradually involving more and more 

 vertebrae. 



Due to the severity of the infection and the extreme grade 

 of deformation of the trunk we may be almost sure that the 

 patient died as the result of it or from some of its complica- 

 tions. The mortality of tuberculosis in the preantibiotic era 

 was 50% and most often occurted in the first two decades of 

 life. Today it is about 5% and confined to an adult or senile 

 age (Ulrich-Bochsler 1982:1322). 



DIFFERENTIAL DIAGNOSIS 



The absence of pathological changes in the remaining skel- 

 eton, revealed macroscopically and by the x-rays, as well as 

 the evidence of the psoas abscesses are strong arguments 

 against other diagnostic possibilities (Steinbock 1976:176, 

 179). The multiplicity of lytic foci in such a great number of 

 vertebral bodies could be produced by blastomycosis, but in 

 it the lesions are almost only destructive, with a punched-out 

 appearance and with little new bone growth. It involves also 

 neural arches and, beside the spine, affects ribs and other 

 bones (Zimmerman and Kelley 1982:89). In pyogenic os- 

 teomyelitis of the spine such a great extent and massive de- 

 struction of several vertebral bodies leading to an angular 

 kyphosis and paravertebral abscesses are uncommon (Ortner 

 and Putschar 1981:149). The pus, penetrating bone cortex, 

 leads to new bone formation with irtegular thickening and 

 cloacae in the involucrum (Zimmerman and Kelley 1982:93- 

 94). 



SOCIAL IMPLICATIONS 



The rapid progression and severity of the process forced the 

 patient to lie in his bed and be nursed by his family or neigh- 

 bors. The exaggerated deformity of the spine with extreme 

 compression of internal organs prevented standing, walking 

 and working. He became fully dependent on social support. 

 This state did not last, however, for a long time. The short 

 course of the disease is reflected in the preservation of his 

 relatively robust and muscular body. 



COURSE OF THE DISEASE 



Our young man caught the disease after the end of his growth 

 period, since otherwise adaptive increase of anterior heights 

 of vertebrae would have appeared. With regard to his age at 

 death, there is a span of about seven to nine years in which the 

 process could occur. It seems, however, probable that it 

 lasted for a far shorter period. Most probably the body of TIO 

 was first destroyed, later an abscess involved the left LI, and 

 finally another abscess was evacuated from Til, leaving 

 there remnants of its cavity. More than a single extension into 



Zannb Paleopalhotogy Symp. 1988 



Literary data on vertebral tuberculosis 

 in Egypt and Nubia 



Since it is a disease of at least neolithic antiquity, associated 

 with drinking milk of cows infected by the bovine type of 

 Mycohacterium tubercuhsia, from which the human type 

 developed later by microevolution (Manchester 1983:39- 

 40), the occurrence of tuberculosis in ancient Egypt and 

 Nubia may well be expected. Milking there became very 

 important as expressed in the widespread cult of the cow- 

 goddess Hathor, and there was a high population density in 



