262 • James M. Tenney 



3. Problems with the investigative process 



a. oversight (not seeing the lesion) 



b. inexperience (not recognizing the lesion, if seen) 



c. not seeing the lesion because it is too small to be de- 

 fected visually on the surface 



d. clerical misidentification 



4. Problems related to diagnosis 



a. pseudopathology (Wells 1967) 



b. determination of normal and range of normal 

 (Dastugue 1986) 



c. insufficient criteria present to support the diagnosis 

 given 



d. the lesion seen represents a disease no longer pres- 

 ent, or one rarely seen 



e. modem-day incidence not applicable owing to 

 changing longevity, better treatment, etc. 



5. Problems related to conclusions 



a. even if the diagnosis is correct, there may be insuffi- 

 cient numbers to have statistical significance. 



It is with one of these areas, problems related to diagnosis, 

 that some progress could be made. First, it should be recog- 

 nized that negative findings do not exclude a disease process, 

 as the disease may have had a fulminant course or the individ- 

 ual may have died of intercurrent disease of some other sort 

 before his primary disease had had time to manifest its full 

 expression. The problem of host resistance is one of the 

 important issues that faces paleopathologists, and is also one 

 of the potentially more rewarding products of our efforts. The 

 matter of provenience is obviously essential. It is difficult to 

 appreciate the paleopathologic, paleoepidemiologic or any 

 other usefulness of a diagnosis such as "possible carcinoma 

 in a mummy of unknown provenience." Quite aside from 

 this, matters of provenience become important in diagnosing 

 a given disease — did it exist during the same era and in the 

 same geographical area as the individual? We know that 

 diseases have their own evolution, with some disappearing 

 (smallpox, poliomyelitis) and others appearing apparently de 

 novo (AIDS). Some diseases change their geographic dis- 

 tribution depending on socioeconomic and other factors 

 (measles, cancrum oris). Vaccinations, antibiotics, and pub- 

 lic health measures determine these changes in geographic 

 distribution to quite an extent, although not entirely. The 

 form as well as the manifestation and severity of a given 

 disease are variable. 



Diagnostic criteria for disease need to be established. An 

 example of criteria derived for a very difficult group of dis- 

 eases is given for the treponematoses (Hackett 1978). Where 

 insufficient criteria are present for a specific diagnosis, one 

 should not be made. 



Current practice 



In modem clinical medicine, diagnostic criteria are estab- 

 lished and well known for carcinoma. They all ultimately 

 depend upon an unequivocal, microscopic appearance of a 

 representative tissue biopsy for definitive diagnosis. This is 

 the state of the art, and has been for decades, whether the 

 carcinoma be of breast, colon, prostate or some other site. 

 Under normal circumstances there is a definite, diagnostic 

 sequence of events: 



HISTORY . The patient 's complaint that brings him to the phy- 

 sician, along with related matters such as duration, family 

 history, environment, and so forth. 



PHYSICAL EXAMINATION. The presence of a lump in the 

 breast, abdominal mass, enlarged liver, or stony hard pros- 

 tate gland may be noted. 



These two items, the history and physical examination, 

 suggest a differential diagnosis. A plan is then made to nar- 

 row the list by ancillary methods. 



RADIOLOGICAL STUDIES. X-ray, computed tomagraphy (CT) 

 scan, magnetic resonance imaging (MRI), and so forth, may 

 show a distribution or pattern of bony and soft tissue changes 

 to suggest a diagnosis of carcinoma and occasionally even a 

 likely primary site. 



LABORATORY STUDIES. Certain blood tests such as serum 

 levels of carcinoembryonic antigen (CEA; elevated in car- 

 cinoma of the colon), serum prostatic acid phosphatase (ele- 

 vated in carcinoma of the prostate), and serum alkaline phos- 

 phatase (reflecting bony destruction/regeneration from any 

 cause) are sometimes useful. Serum protein electrophoresis 

 and Immunoelectrophoresis are virtually diagnostic of multi- 

 ple myeloma when positive. 



As the differential diagnosis is narrowed, an operative 

 procedure is planned: whether to remove the entire tumor 

 (excisional biopsy) and possibly attempt a cure, or to remove 

 only a portion of the tumor (incisional biopsy). Both result in 

 obtaining sufficient tissue for microscopic confirmation of 

 the clinical impression. 



It is now, and only now, that the "100% certain diagnosis" 

 can be made, and up to this point, there is still a differential 

 diagnosis. The question arises as to whether there is a place 

 for something less than the "100% certain diagnosis." In 

 some instances a patient is terminally ill or his condition is 

 too poor to consider surgery. In other cases, prognosis is too 

 poor to attempt any extensive diagnostic workup, and the 

 only procedures considered are to be palliative. Even then, 

 some sort of assurance other than a history and physical 



Zagreb Paleopathology Symp. 1988 



