AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 121:19 (2003)
Bayes Theorem in Paleopathological Diagnosis
Steven N. Byers1* and Charlotte A. Roberts2
1
Department of Anthropology, University of New Mexico, Albuquerque New Mexico 87131-1086
2
Department of Archaeology, University of Durham, Durham DH1 3LE, England, UK
KEY WORDS paleopathology; Bayes theorem; diagnosis
ABSTRACT The utility of Bayes theorem in paleo-
pathological diagnoses is explored. Since this theorem has
been used heavily by modern clinical medicine, its useful-
ness in that eld is described rst. Next, the mechanics of
the theorem are discussed, along with methods for deriv-
ing the prior probabilities needed for its application. Fol-
One of the most vexing problems facing paleo-
pathologists is the accurate identication of patho-
logical conditions in ancient osteological remains. As
discussed by numerous workers (Brothwell, 1981;
Ortner, 1992; Waldron, 1994; Miller et al., 1996;
Lovell, 2000), there are many difculties associated
with this process, because different pathological con-
ditions have similar osteological manifestations
(Ortner, 1992; Aufderheide and Rodriquez-Martin,
1998). Since the presence of pathologies has been
used to explain aspects of life in past populations
(Steinbock, 1976; Ortner and Putschar, 1981; Buik-
stra and Ubelaker, 1994), accuracy of diagnosis is of
paramount importance. Although many good publi-
cations describe the visual and radiographic appear-
ance of various diseases, traumata, and other depar-
tures from normal bone form (e.g., Brothwell and
Sandison, 1967; Steinbock, 1976; Ortner and Put-
schar, 1981; Zimmerman and Kelley, 1982; Roberts
and Manchester, 1995; Aufderheide and Rodrguez-
Martin, 1998), very little attention is given to meth-
ods for resolving problems in differential diagnosis.
When faced with a bone containing abnormalities
that could be caused by any number of pathological
processes, it is up to the paleopathologist to use his
or her best judgment to correctly identify the caus-
ative agent.
The lack of methods for untangling conicting in-
formation has often resulted in fairly strong dis-
agreements among researchers. Miller et al. (1996)
showed that even persons experienced in the prac-
tical aspects of skeletal biology, paleopathology, and
medicine often offer incorrect judgments, and/or
may be unsure of a precise pathological classica-
tion. Using dry bone lesions of known etiology, these
authors compiled data on the accuracy of diagnoses
made by persons attending workshops in 1990 and
1991 at the annual meetings of the Paleopathology
Association. Their results showed that attendees
2003 WILEY-LISS, INC.
lowing this, the sources of these prior probabilities and
their accompanying problems in paleopathology are con-
sidered. Finally, an application using prehistoric rib le-
sions is presented to demonstrate the utility of this
method to paleopathology. Am J Phys Anthropol 121:19,
2003. 2003 Wiley-Liss, Inc.
placed only 42.9% of provided specimens into their
correct pathological category (e.g., anomaly, trauma-
repair, or metabolic). Even worse, when identica-
tions of specic conditions were attempted (e.g.,
Pagets disease, rheumatoid arthritis), only 28.6% of
specimens were correctly assigned. These rather dis-
tressing results underscore the need for techniques
that aid in the identication of dry bone pathologies.
In the paleopathological literature, few works de-
scribe methods focused specically on differential
diagnosis. Steinbock (1976), while devoting consid-
erable attention to differential diagnosis, did not
present a general method for dealing with this prob-
lem. Buikstra (1976) used a key diagram (also called
a decision tree) as a method to aid in the identica-
tion of tuberculosis in the spines of Caribou Eskimo.
From an assemblage of defects that also could indi-
cate rheumatoid arthritis, blastomycosis, brucello-
sis, and other diseases, she derived the most likely
diagnosis of a pathological specimen by tracing the
expression of traits along different paths for differ-
ent individuals. (Rogers et al., 1987 presented infor-
mation that could be used in a similar manner when
differentiating between various arthropathies.) An-
other method, typied by Blackman et al. (1991),
involves making a decision table to relate diseases to
their concomitant pathological signs and other rele-
vant data (e.g., demographics). This is constructed
by listing signs of pathological conditions (or other
data that can be used in a diagnosis) down the
*Correspondence to: Steven N. Byers, Department of Anthropology,
University of New Mexico, Albuquerque, NM 87131.
Received 24 August 2001; accepted 30 May 2002.
DOI 10.1002/ajpa.10164
2 S.N. BYERS AND C.A. ROBERTS

left-hand side of a table, while the different patho- TABLE 1. Pathological conditions explored using Bayes
logical entities that contain these signs are arranged theorem or Bayesian logic
across the top as column headings. The expression of Pathological condition Reference
each sign or other data for a condition is entered in Alzheimers disease Prince, 1996
the appropriate conuence of column and row, and a Ankylosing spondylitis Diffey et al., 1985
diagnosis is determined by the column that best Appendicitis Edwards and Davies, 1984
describes the skeleton(s) under study. Unfortu- Asthma Perpina et al., 1993
Bone tumors Lodwick et al., 1963
nately, these are the only examples from the litera- Cancer Du Boulay et al., 1977; Kahn et
ture involving methods of paleopathological diagno- al., 1997; Lind and Singer,
sis. Thus, this area is in need of concentrated 1986; Montironi et al., 1994,
attention if a greater battery of procedures is to be 1998; Pastor et al., 1997
Colonic diseases Siles et al., 1997; van de
available to the osteological researcher. One source Merwe, 1983
of such methods is the techniques used by clinicians Coronary artery disease Diamond et al., 1980
to diagnose pathologies in living persons. Cushings Syndrome Nugent et al., 1964
Gallbladder disease Haddawy et al., 1994
In the medical literature, most solutions to the prob- Hearing loss Phaneuf et al., 1985
lem of diagnosis can be subsumed under the overall Heart disease Warner et al., 1961, 1964;
heading of decision support systems (DSSs). In a good Reale et al., 1968
overview, Degoulet and Fieschi (1997) distinguished Hypertension Blinowska et al., 1991;
Elijovich and Laffer, 1992
four methodological approaches underlying these sys- Jaundice Malchow-Moller et al., 1986
tems: mathematics, expert systems, neural networks, Liver and biliary Begon et al., 1979
and probability. Mathematical models involve calcu- diseases
lating functional relationships between physical Lupus Somogyi et al., 1993
Mental retardation Mani et al., 1997
and/or physiological parameters of interest (e.g., blood Multiple sclerosis Blinowska et al., 1992
vessel size and ow rate). Because these functions do Osteomyelitis Worbel and Connolly, 1998
not calculate categorical variables that would repre- Pneumonia Aronsky and Haug, 1998
Rheumatological Bernelot Moens and van der
sent pathological conditions, their applicability to di- disorders Korst, 1991, 1992
agnosis is limited. Expert systems are computer appli- Rheumatoid arthritis Bernelot Moens et al., 1992
cations that use articial intelligence languages to Streptococcal infections Poses et al., 1986
mimic the methods used by the most skillful diagnos- Thyroid disease Overall and Williams, 1963
Viral infections Berg, 1981
ticians, while neural networks are computer systems
that mimic the structure and function of the human
brain. The effectiveness of these two approaches is still
being researched. Finally, probabilistic methods use found that the theorem was correct 9193% of the
various observed frequencies of pathological condi- time, which is a signicant increase over the 50%
tions in conjunction with their signs and/or symptoms probability due to chance alone. In addition, where
to develop probabilities of these conditions in patients reported, the theorem performs as well as, or better
presenting similar clinical pictures. A number of sta- than, the initial diagnosis by physicians. Since the
tistical procedures are available in this method, in- purpose of both modern clinical medicine and paleo-
cluding Bayes theorem, logistic regression and/or dis- pathology is accurate diagnosis, the information in
crimination, and linear discriminant analysis. Tables 1 and 2 indicates that this method should be
Of the four methodological approaches, probabil- useful in paleopathology. Therefore, this paper ex-
ity models using Bayesian theory and especially plores how Bayes theorem could be applied to pa-
Bayes theorem are the most widely employed. Table leopathology. The issues and problems surrounding
1 presents a partial list drawn from the medical its application will be discussed, and an example
literature of pathological conditions to which clini- given. It is hoped that the presentation here will
cians have applied Bayes theorem or Bayesian the- stimulate further research into this promising
ory to the problem of diagnosis. As can be seen, even method.
an incomplete list is extensive, indicating that the
BAYES THEOREM
theory has been widely studied by the medical es-
tablishment. Furthermore, Bayes theorem has been Bayes theorem describes how knowledge of prior
shown to be as good as, or better than, both clinical probabilities can be used to calculate the probability
diagnoses and guessing. Table 2 presents results of unknown events in many subject areas, including
from a sample of medical studies where Bayes the- the sciences, the humanities, and even games of
orem was used to diagnose a number of conditions chance. In problems involving the diagnosis of mod-
whose correct identication was obtained from ern disease, the prior probabilities are both the
complete testing. As can be seen, in almost all stud- prevalences of pathological conditions and the like-
ies, Bayes theorem predicts the correct diagnoses lihoods of signs found within those conditions.
better (usually much better) than expected from Prevalences are the frequencies with which patho-
chance alone. For example, when applied to the logical conditions (i.e., infectious diseases, nutri-
problem of differentiating appendicitis from other tional deciencies, trauma, and any other departure
abdominal problems, Edwards and Davies (1984) from normal structure and function) occur in popu-
 DIAGNOSIS USING BAYES THEOREM 3
TABLE 2. Accuracy of Bayes theorem in selected clinical studies1

General pathological Number of % correct diagnosis

condition specic conditions Clinicians Bayes theorem Reference
Congenital heart disease 33 73.2 81.4 Warner et al., 1961
Congenital heart disease 94 73.2 81.8 Reale et al., 1968
Polycythemic states 5 6576 95 Bishop and Warner, 1969
Intrathoracic radiographs 15 nr 53 Alperovitch and Lellouch,
1974
Thoracic conditions 3 nr 73 McNeil and Sherman,
1978
Gastrointestinal bleeding 2 nr 4969 Ohmann et al., 1988
Acute abdominal pain 9 76 74 Gammerman and
Thatcher, 1991
Liver disease 40 nr 6477 Croft and Mochol, 1974
Appendicitis 2 7689 9193 Edwards and Davies,
1984
1
nr, not reported.

lations. Likelihoods are the frequencies with which
signs (i.e., visually observable characteristics, symp-
tomatic complaints, the results of medical tests, lo-
cation of abnormalities within the body, and any
other attribute that can be used to identify a patho-
logical condition) appear within the conditions for
which the prevalence is known.
From these statistics, the simplest form of Bayes
theorem can be used to calculate the probability of
the presence or absence of an ailment, given its
prevalence and the likelihood of a single sign occur-
ring in people suffering from that condition. In its
general form, it can be extended for multiple dis-
eases and multiple signs so that the probability of a
pathological condition can be calculated as:
PC i S 1 , S 2 . . . S s
PC i LS 1 C i S 2 C i . . . S S C i
(1)
PC LS C S C
C
i 1 i 2 i . . . S S C i
i1
where:
P(Ci|S1, S2 . . . Ss) Probability of pathologi-
cal condition i, given
the presence of signs 1,
2, etc.
P(Ci) Prevalence of pathologi-
cal condition i
L(S1|Ci, S2|Ci . . .
ScCi) Likelihood of sign 1,
sign 2, etc. in patholog-
ical condition i
From equation (1), it can be seen that any number of
conditions (Cc) or signs (Ss) can be used in the cal-
culation of the probability of a disorder. In the med-
ical literature, the number of conditions analyzed
has varied from 1 (e.g., Ohmann et al., 1988) to
almost 100 (e.g., Reale et al., 1968), with most re-
searchers limiting their study to under 30 (e.g., Al-
perovitch and Lellouch, 1974; McNeil and Sherman,
1978; Gammerman and Thatcher, 1991). The num-
ber of signs used has varied from fewer than 20 (e.g.,
Sherman, 1978; Bishop and Warner, 1969) to
around 30 (e.g., Alperovitch and Lellouch, 1974; Fry-
back, 1978; Gammerman and Thatcher, 1991) and
as high as 50 (e.g., Warner et al., 1961).
Once these values are determined, Bayes theorem
can aid in diagnosis in the following manner. First,
those signs found in a patient are identied, and
their prior likelihoods are entered into equation (1).
This equation is then calculated for each pathologi-
cal condition for which prevalences exist. The condi-
tion with the highest resulting probability would be
the most likely diagnosis. Given this, it seems rea-
sonable that Bayes theorem has applications to di-
agnosing osteopathological conditions. Since modern
medicine has demonstrated its efcacy and since
both paleopathologists and clinicians have similar
goals, the theorem should help meet the aforemen-
tioned need for methods in paleopathological diag-
nosis. All that needs to be done is to derive the
necessary prior probabilities, and equation (1) could
be applied.
Prevalences for each pathological condition can be
calculated according to the following formula:
N Ci
PC i (2)
N
where:
P(Ci) Prevalence of pathological condition i
NCi Number of people with pathological condi-
tion i
N Total number of people in the population
As can be seen, the number of individuals suffer-
ing from a condition is simply divided by the total
number of individuals from the population on which
the statistic is based. This calculation is carried out
for each pathological condition.
The computation of likelihoods follows a similar
course. This statistic is computed by dividing the
number of individuals having both a sign and a
pathological condition by the total number of indi-
4 S.N. BYERS AND C.A. ROBERTS
viduals suffering from that pathological condition.
Thus:
NS j C i
LS j C i (3)
N Ci
where:
L(Sj|Ci) Likelihood of sign j in condition i
N(Sj|Ci) Number of persons exhibiting sign j in
condition i
NCi Number of persons with condition i
This calculation is carried out on all signs for a
pathological condition.
As can be seen, to apply Bayes theorem to paleo-
pathology requires only that the prevalences and
likelihoods be available for input to equation (1).
However, a number of issues and problems sur-
rounding their derivation require explanation.
PREVALENCES AND LIKELIHOODS IN
PALEOPATHOLOGY
In modern medicine, most researchers calculate
prevalences and likelihoods from patients seen in a
clinical setting for whom positive diagnoses have
been obtained (e.g., Ledley and Lusted, 1959;
Warner et al., 1961; Reale et al., 1968; Bishop and
Warner, 1969; Croft and Machol, 1974; Alperovitch
and Lellouch, 1974; Norusis and Jacquez, 1975;
Starmer and Lee, 1976; Fryback, 1978; McNeil and
Sherman, 1978; Ohmann et al., 1988; Gammerman
and Thatcher, 1991). Since similar information is
not available to paleopathologists, these prior prob-
abilities have to be derived elsewhere. One obvious
source is health statistics on living populations, both
old data collected by industrialized countries from
the 1800s and early 1900s as well as new statistics
published by modern health agencies. Another
source is data that could be gathered from the col-
lections of human skeletons, such as the Terry and
Todd Collections and the newer but smaller collec-
tions at places such as the University of New Mexico
and the University of Tennessee, Knoxville.
Before any of these are used to compute prior
probabilities, a number of issues must be consid-
ered. The rst is, how representative of prehistoric
populations are the health statistics and data that
are derived from skeletal collections? It seems rea-
sonable that the older the data (e.g., old health sta-
tistics, data from the Terry and Todd Collections),
the more likely they are to reect the prehistoric
condition because the effects of modern therapies
would not mitigate (or eliminate) the defects used in
the determination of prevalences and likelihoods.
Thus, the people on whom these prior probabilities
would be computed are more analogous to past pop-
ulations than the people represented in newer
sources. However, these samples contain biases of
unknown effect, e.g., old health statistics are avail-
able only from industrialized countries, and the
Terry and Todd Collections were derived from peo-
ple of the midwestern United States in the earlier
part of the 1900s. Newer skeletal collections have
comparable problems with sample bias, i.e., they are
derived from specic regions in the United States.
Similarly, although modern health statistics from
Third World countries may be more representative
of past populations because they derive from people
living a traditional lifestyle without access to mod-
ern therapies, the impact of diseases when people
were rst exposed to them may have been different
than they are today (Brothwell, 1967; Ortner and
Pustchar, 1981). This would bias prevalences and
likelihoods calculated from these statistics. In sum,
all sources of prior probabilities have problems with
representativeness; however, this simply character-
izes the state of the science today. For example, the
Terry and Todd Collections provide much of the
information used by human skeletal biologists in
osteological studies; this makes them the source of
standards in physical anthropology, whether or not
they are representative of the population at large.
Also, as will be discussed below, the effect of this
problem is not so critical as to invalidate the
method.
The next issue to consider is the accuracy of the
diagnoses in these sources. As pointed out by Roth-
schild et al. (1990) when studying the Terry Collec-
tion, modern criteria for the identication of patho-
logical conditions were unavailable in earlier times.
Therefore, prevalences and likelihoods derived from
early health statistics in industrialized countries, or
calculated from older skeletal series, can be ques-
tioned. For example, although some support the di-
agnoses seen in the records for the Terry Collection
(David Hunt, personal communication), others have
noted that a number of these are laughable (Stan
Rhine, personal communication). Despite these pos-
sible problems, it seems unlikely that all (or even
most) of the diagnoses in early health statistics or
skeletal collections are incorrect; thus, their use in
computing prior probabilities is supported. Another
problem with diagnoses is that health statistics and
skeletal collection records list the presence of a dis-
ease usually only if it was the cause of death. Dis-
eases suffered during life but not causing death are
noted only infrequently (e.g., Terry Collection), if at
all (e.g., modern health statistics).
From the above discussion, it is evident that ob-
taining prevalences and likelihoods that are appli-
cable to past populations is a difcult endeavor, at
best. Although the problems seem insurmountable,
there is evidence that their resolution may not need
to meet all of the criteria demanded by science. In a
potentially devastating article, Miettinen and Caro
(1994) point out unsolvable epistemological prob-
lems with the calculation of these prior probabilities
in modern clinical medicine. Their thesis is that
the application of Bayes theorem to the identica-
tion of disease is based on untenable premises. At
the same time, however, they openly admit that
feasible diagnostic probabilities are calculable. This
 DIAGNOSIS USING BAYES THEOREM
is encouraging for paleopathologists. If modern cli-
nicians can compute useful probabilities (as seen by
the number of pathological conditions in Table 2)
despite underlying problems with prevalences and
likelihoods, Bayes theorem almost certainly has ap-
plication to the identication of osteological mani-
festations of diseases in past populations. In addi-
tion, it has been shown that the theorem is robust,
since it yields useful results even when the assump-
tions on which it is based (e.g., independence of
signs; see below) are violated in a limited manner.
Thus, despite the difculties surrounding prior
probabilities, Bayes theorem deserves the attention
of paleopathologists.
No matter which source is chosen for prevalences
and likelihoods, a number of issues surrounding
these statistics must be considered. For prevalences,
four of these are of major importance. First, the list
of pathological conditions for which prevalences are
calculated must be exhaustive, i.e., all possible
prevalences must be available for use in Bayes the-
orem. In the clinical literature, this problem is
solved by identifying the diseases specically being
studied and then creating a normal or other cat- ter, 1995; Aufderheide and Rodrguez-Martin, 1998;
egory for all other conditions (e.g., Warner et al.,
1961; McNeil and Sherman, 1978). Another method
for dealing with this is to restrict the number of
diseases being examined (e.g., Alperovitch and Lel-
louch, 1974; Gammerman and Thatcher, 1991), so
that diagnoses are attempted only on patients suf-
fering from specic pathologies.
A second issue is that prevalences are calculated for
conditions that are mutually exclusive. Thus, a person
cannot have more than one of the C conditions ap-
pearing in equation (1). Unfortunately, despite the fact
that patients suffering from multiple diseases are part
of the clinical world, most workers simply ignore this
problem (e.g., Warner et al., 1961; Reale et al., 1968;
Bishop and Warner, 1969; Alperovitch and Lellouch,
1974; Gammerman and Thatcher, 1991), while only a
few (e.g., Reale et al., 1968) create disease categories
which are combinations of individual conditions.
A third issue involves the sum of the prevalences.
Traditionally, the prevalences of all diseases add up
to 1 because the P(Ci)s are computed from a popu-
lation of individuals suffering from any number of
pathological conditions of interest. However, despite
the widespread use of this standard, it is not neces-
sary for the proper application of Bayes theorem.
Since this formula describes the relationship be-
tween probabilities, any values of prevalence that
are considered valid can be used. The only require-
ment is that the relationship between the frequency
of diseases must be maintained (i.e., if one disease is
twice as common as another, the prevalence of the
rst must be twice that of the second). Similarly, if
only the rank order of prevalences is known, Bayes
theorem still can be applied (for an example, see
Horbar, 1983).
The nal complication affecting prevalences are
intrinsic and extrinsic population factors that inu-
5
ence the rate at which persons will suffer patholog-
ical conditions. For example, the frequency of genet-
ically induced diseases such as sickle-cell anemia
and thalassemia, which can have osteological man-
ifestations (Cooley et al., 1927; Sebes and Diggs,
1979; Whipple and Bradford, 1932), would cause
prevalences in some areas of the world to be differ-
ent from those in other areas. Similarly, environ-
mental factors such as climate and weather, which
long have been recognized to be correlated with the
appearance of diseases and often are seen to be
related to seasonality (Yan, 2000; De Garine, 1993;
Lukacs and Walimbe, 1998; Steinbock, 1976; Ortner
and Putschar, 1981; Aufderheide and Rodrguez-
Martin, 1998), also make the calculation of this sta-
tistic dependent on geographic location. Even cul-
tural factors such as dietary elements and their
combinations (e.g., Larsen, 1995; El-Najar et al.,
1975), or simply the aggregation of people in towns
and cities (Brothwell, 1967; Howe, 1997; Schell and
Ulijaszek, 1999), would affect the frequency of dis-
eases. Finally, many workers (e.g., Steinbock, 1976;
Ortner and Putschar, 1981; Roberts and Manches-
Grauer and Stuart-Macadam, 1998; Pollard and
Hyatt, 1999) indicate that demographic factors such
as sex and age are correlated with pathological con-
ditions, which then would affect the calculation of
prevalences.
Likelihoods have three issues to consider. The
rst is the simple identication of signs. Ortner
(1994) delineated two factors that are important
when describing a sign of a pathological condition:
what is its nature, and where is it located? To these
can be added demographic characteristics such as
ancestral group, age, and sex (Ortner and Pustchar,
1981). Unfortunately, present methods for describ-
ing the nature of abnormalities are not yet as well-
developed as paleopathologists might wish (Ortner,
1991, 1992, 1994). Generally four characteristics,
and their combinations, have been presented as in-
dicators of a pathologically induced change (Ortner
and Putschar, 1981; Ortner, 1992, 1994): abnormal
bone loss, abnormal bone gain, abnormal shape, and
abnormal size. In addition to these, the amount of
bone that is affected, either in absolute measure or
percent of the total bone, is similarly important
(Buikstra and Ubelaker, 1994).
Fortunately, the other feature of description (i.e.,
location of lesions) is fairly easy to dene. This in-
volves naming the bone(s) manifesting the condi-
tion(s), and the placement of defects within it/them
(Ortner, 1992). Buikstra and Ubelaker (1994) thor-
oughly described this latter factor in a typical long
bone as involving side (i.e., right, left), section (i.e.,
diaphysis, metaphysis, epiphysis), and aspect (i.e.,
medial vs. lateral, proximal vs. distal, anterior vs.
posterior, and circumferential). Similar descriptions
are available for other bones of the skeleton, and
more detail could be useful.
6 S.N. BYERS AND C.A. ROBERTS
The second issue affecting likelihoods is the as-
sumption of independence, i.e., the occurrence of one
sign does not depend on the presence of another.
Since many co-occur, unusually high or low proba-
bilities may result from Bayes theorem calculations,
thereby causing misclassication of diseases. In the
medical literature, this problem has been ap-
proached either by ignoring dependencies (called
simple Bayes by Gammerman and Thatcher, 1991)
or by accounting for these in the calculation of dis-
ease probabilities (termed proper Bayes by Gam-
merman and Thatcher, 1991). Some studies show
that misclassication goes down with proper
Bayes (Norusis and Jacquez, 1975; Russek et al.,
1983; Ohmann et al., 1988; Chard, 1989), while oth-
ers show an increase in misclassication when de-
pendencies are taken into account (Fryback, 1978;
Gammerman and Thatcher, 1991). On the whole,
however, the data indicate that misclassication
rates between simple and proper Bayes are not
great when a small number of signs (e.g., fewer than
10) is used (see Norusis and Jacquez, 1975; Fryback,
1978; Russek et al., 1983; Ohmann et al., 1988;
Chard, 1989). Thus, although the assumption of in-
dependence between signs is theoretically incorrect,
Bayes theorem is robust enough to be of value in
diagnosis, even when this assumption is violated in
a limited manner.
The last problem involves determining which
signs to employ in the calculation of Bayes theorem.
In modern clinical medicine where many signs are
considered, some researchers check rst for causally
related (dependent) signs and use only the one from
the group with the highest likelihood (e.g., Warner
et al., 1961; Ohmann et al., 1988; Gammerman and
Thatcher, 1991). Others only use signs that occur
more often in one disease than another (e.g., McNeil
and Sherman, 1978; Norusis and Jacquez, 1975).
This information indicates that only the likelihoods
from uncorrelated (independent) signs that have fre-
quencies that are either high (i.e., approaching 1) or
low (i.e., approaching 0) should be used in the cal-
culation of the theorem, while those whose frequen-
cies are correlated and nearly equal in all diseases
should be avoided. However, as discussed above, this
issue can be ignored if fewer than 10 signs are being
considered.
PALEOPATHOLOGICAL EXAMPLE
As an example of how Bayes theorem could be
applied to paleopathology, one of the authors
(S.N.B.) discovered rib fragments with osteoprolif-
erative lesions (Fig. 1) in a collection of bone exca-
vated by Czajkowski (1934) from Little Woods, a
Native American site in southern Louisiana dated
500 250 BC. Since tuberculosis has been hypothe-
sized to occur prehistorically in the Americas (for a
list of sources, see Powell, 1992), albeit later in time,
it was reasonable to question if these lesions repre-
sented that disease. Unfortunately, the ribs were
from an ossuary where considerable disarticulation
Fig. 1. Osteoproliferative lesion on internal surface of a rib
from prehistoric Louisiana.
and fragmentation of osteological material had oc-
curred. Thus, there were no associated skeletal ele-
ments to aid in the diagnosis or any opportunity to
look at the distribution pattern of lesions.
Roberts et al. (1994) researched the incidence of
similar osteoproliferative lesions in some 380 skele-
tons from the Terry Collection. Their study revealed
lesion frequencies in persons whose deaths were
recorded as being due either to tuberculosis (Tub),
other pulmonary disease (Oth Pul), or nonpulmo-
nary disease (NonPul). These conditions met the
criteria discussed above for the calculation of preva-
lences, i.e., they represented a mutually exclusive
and exhaustive list. In addition, their frequencies
added up to 1.0, and the disease of interest was
identied (in this case, tuberculosis), while diseases
of lesser interest were placed into other categories.
Also, the precept by Ortner (1994, p. 6) that the
nature of the abnormality must rst be specied
was satised by the description osteoproliferative
lesions. Likelihoods then would be based on fre-
quencies concerning location as well as incidence by
age, sex, and other demographic characteristics. In
this case, Roberts et al. (1994) indicated that age,
side, location in thorax, and affected surface of ribs
were useful for distinguishing the three cause-of-
death categories. Also, the independence between
signs was not important, since there were fewer
than 10, making the search for correlation unneces-
sary.
When calculating Bayes theorem, the usual
method is to place the prior probabilities into a table
with diseases arranged as rows, and signs as col-
umns (Warner et al., 1961; Vishnevskiy et al., 1973).
In this manner, the likelihoods of signs within dis-
eases are located at the intersection of the disease
row with the sign column. Table 3 presents a sum-
mary of the data of Roberts et al. (1994) for the three
causes of death. These statistics show that there are
no characteristics that occur only in one disease (i.e.,
likelihood 1.0) and not in the others. Although this
would allow for a more condent diagnosis, this sit-
uation is so rare that it should not be expected.
Second, age at death is a useful characteristic for
determining disease (e.g., persons between ages
26 35 are six times more likely to die of tuberculosis
than from a nonpulmonary disease). Although it is
 DIAGNOSIS USING BAYES THEOREM 7
TABLE 3. Prior probabilities for application of bayes theorem to osteoproliferative lesions
Position of lesions within
Age at death Side of lesion cage Position of lesions on ribs
Cause of death Prevalence 1525 2635 3645 4655 56 One Both Low Mid High All Anterior Lateral Posterior All

Tuberculosis 0.421 0.155 0.316 0.226 0.142 0.161 0.548 0.452 0.019 0.382 0.076 0.204 0.076 0.064 0.057 0.611
Other pulmonary 0.137 0.100 0.100 0.160 0.220 0.420 0.760 0.240 0.020 0.529 0.039 0.137 0.200 0.040 0.080 0.440
Nonpulmonary 0.442 0.049 0.049 0.221 0.221 0.436 0.521 0.479 0.069 0.500 0.050 0.163 0.282 0.043 0.049 0.399

theoretically incorrect to include such frequencies
(see Miettenen and Caro, 1994), they can be used in
calculations because of the robust nature of the the-
orem discussed above.
Since the age, side, and position within the rib
cage cannot be determined for the individual(s) from
Little Woods, the only usable likelihood is the af-
fected rib surface. Because these all are located an-
teriorally (Ant), equation (1) for the three causes of
death are:
PTubAnt
.421*.076
.421*.076 .137*.200 .442*.282
.032 .032
.174
.032 .027 .125 .184
POth PulAnt
.137*.200
.421*.076 .137*.200 .442*.282
.027 .027
.147
.032 .027 .125 .184
PNonPulAnt
.442*.282
.421*.076 .137*.200 .442*.282
.125 .125
.679
.032 .027 .125 .184
These calculations reveal several important points.
First, there is a higher probability that the lesions are
associated with a nonpulmonary cause of death than
with tuberculosis. This is surprising, because Roberts
et al. (1994) showed that tuberculosis is a highly prob-
able cause for these osteoproliferations. However,
since they are not pathognomonic for this infection
(other pulmonary diseases such as pneumonia and
neoplastic disease also exhibit these lesions), the re-
sult here is reasonable. Second, these calculations dou-
ble the probability of correct diagnosis over that due to
chance. That is, all things being equal, there is only a
0.333 probability that a nonpulmonary disease caused
the lesions. Third, the calculations are predicated on
the applicability of Terry Collection frequencies to the
prehistoric peoples of southern Louisiana. The as-
sumption of representativeness of sample prior prob-
abilities has already been discussed; however, for the
purpose of illustration, the sample bias of the Terry
Collection is ignored. Fourth, sometimes probabilities
are not as persuasive as one would like (e.g., the prob-
ability of nonpulmonary cause of death is only P
0.679). However, in other cases, stronger probabilities
result; for example, if these same lesions were found
along the entire surface of both sides of the upper ribs
of a skeleton from an individual who was around 30
years old at the time of death, the probabilities from
Bayes theorem given these four signs would be:
P(Tub|4 Signs) 0.914, P(Oth Pul|4 Signs) 0.018,
and P(NonPul|4 Signs) 0.068, resulting in a better
case for tuberculosis being the cause of the lesions.
Last, given the paucity of data used in the above cal-
culations, diagnosis based solely on the computed
probabilities would be unwarranted. This situation
would be true even in the hypothetical example where
the probabilities were more compelling. It should
never be construed that the results of Bayes theorem
(4)
would be the only basis for developing a diagnosis;
rather, all data should be considered before attempt-
ing to identify a pathological condition.
As a way of reinforcing this last point, consider the
following analysis. Since the question being ex-
plored here is whether or not the osteoproliferative
lesions are due to tuberculosis, other signs of this
(5)
disease should be evident in the skeletal material
despite their disarticulation. According to Ortner
and Putschar (1981), the primary osteological man-
ifestation of tuberculosis is cavitating lesions in the
hemopoietic marrow, with little reactive bone forma-
tion. This defect is found most often in the bodies of
vertebrae, especially the lumbar region, where it
(6)
usually affects two or more bones in the same ver-
tebral column. In the joints, the hip and knee are
affected most often, with destruction of the articular
surfaces followed by fusion (ankylosis). Among 95
complete or nearly complete vertebral bodies from
Little Woods, there is only one which exhibits a lytic
lesion that approximates the cavitations expected in
tuberculosis, and none of the joints show destruction
and ankylosis. Thus, a diagnosis of tuberculosis for
these rib fragments is unwarranted, and the pres-
ence of this disease at the site cannot be proven with
these data. Unfortunately, because nonpulmonary
causes of death were not investigated further by
Roberts et al. (1994), nothing additional can be as-
certained as to the cause of these lesions.
CONCLUSIONS
To summarize, Bayes theorem has been used suc-
cessfully by the medical profession to aid in the
diagnosis of disease in a clinical setting. Although
physicians have the advantage of a larger range of
tests as well as therapies whose effectiveness can be
8 S.N. BYERS AND C.A. ROBERTS
used to support a diagnosis, the method is still ap-
plicable to paleopathology. Despite the fact that
there are difculties in obtaining reasonable preva-
lences and likelihoods, the derivation of these sta-
tistics would make it possible to calculate the prob-
ability of any number of pathological conditions for
skeletons manifesting osteological abnormalities.
Prevalence and likelihood statistics could be derived
by a comprehensive study of all pathologies in the
Terry and Todd Collections as well as other smaller
skeletal series, using a data-gathering instrument
that includes, and goes beyond, those characteristics
described by Buikstra and Ubelaker (1994), Lovell
(2000), or Byers (2002). Additionally, information on
prevalences could be obtained from modern health
statistics, especially from the Third World, as a
means of checking the applicability of skeletal series
data to the world at large. Information gathered in
this manner could be used to develop a computerized
diagnosis system (S.N.B. has a prototype of such a
system, which is available by e-mailing him at
j708@unm.edu), which would calculate probabilities
that could support or refute diagnoses developed
using more traditional methods. This would provide
more information for the diagnostic process, thereby
increasing the accuracy with which paleopathologi-
cal conditions are identied.
LITERATURE CITED
Alperovitch A, Lellouch J. 1974. Methods for aiding medical de-
cision: application to diagnosis of round intra-thoracic x-ray
picture. Comput Biomed Res 7:127141.
Aronsky D, Haug PJ. 1998. Diagnosing community-acquired
pneumonia with a Bayesian network. Proc AMAI Symp 1998:
632 636.
Aufderheide AC, Rodrguez-Martin C. 1998. The Cambridge en-
cyclopedia of human paleopathology. Cambridge: Cambridge
University Press.
Begon F, Lockhart AM, Metreau JM, Dhumeaux DA. 1979. Com-
puter-aided system for the diagnosis of hepato-biliary diseases.
A comparison with the performance of physicians. Med Inf
(Lond) 4:35 42.
Berg AO. 1981. Case-control diagnosis and Bayesian inference in
common viral infections. J Fam Pract 12:10171021.
Bernelot Moens HJ, van der Korst JK. 1991. Comparison of
rheumatological diagnoses by a Bayesian program and by phy-
sicians. Methods Inf Med 30:187193.
Bernelot Moens HJ, van der Korst JK. 1992. Development and
validation of a computer program using Bayes theorem to
support diagnosis of rheumatic disorders. Ann Rheum Dis 51:
266 271.
Bernelot Moens HJ, Hirshberg AJ, Claessens AA. 1992. Data-
source effects on the sensitivities and specicities of clinical
features in the diagnosis of rheumatoid arthritis: the relevance
of multiple sources of knowledge for a decision-support system.
Med Decis Making 12:250 258.
Bishop CR, Warner HR. 1969. A mathematical approach to med-
ical diagnosis: application to polycythemic states utilizing clin-
ical ndings with values continuously distributed. Comput
Biomed Res 2:486 493.
Blackman J, Allison MJ, Aufderheide, Oldroyd N, Steinbock RT.
1991. Secondary hyperparathyroidism in an Andean mummy.
In: Ortner DJ, Aufderheide AC, editors. Human paleopathol-
ogy: current syntheses and future options. Washington, DC:
Smithsonian Institution Press. p 291296.
Blinowska A, Chatellier G, Bernier J, Lavril M. 1991. Bayesian
statistics as applied to hypertension diagnosis. IEEE Trans
Biomed Eng 38:699 706.
Blinowska A, Verroust J, Malapert D. 1992. Bayesian statistics
as applied to multiple sclerosis diagnosis by evoked potentials.
Electromyogr Clin Neurophysiol 32:1725.
Brothwell DR. 1967. The bio-cultural background to disease. In:
Brothwell DR, Sandision AT, editors. Diseases in antiquity.
Springeld, IL: C.C. Thomas. p 56 68.
Brothwell DR. 1981. Digging up bones, 3rd ed. Ithaca, NY: Cor-
nell University Press.
Brothwell DR, Sandison AT. 1967. Diseases in antiquity. Spring-
eld, IL: C.C. Thomas.
Buikstra JE. 1976. The caribou Eskimo: general and specic
disease. Am J Phys Anthropol 45:351368.
Buikstra JE, Ubelaker DL. 1994. Standards for data collection
from human skeletal remains. Arkansas Archeological Survey
research series no. 44. Fayetteville, AR: Arkansas Archeologi-
cal Survey.
Byers SN. 2002. A model for the diagnostic process in paleopa-
thology. Paleopathol Newslett 117:1118.
Chard T. 1989. The effect of dependence on the performance of
Bayes theorem: an evaluation using computer simulation.
Comput Methods Programs Biomed 29:1519.
Cooley TB, Witner ER, Lee P. 1927. Anemia in children. Am J Dis
Child 34:347363.
Croft DJ, Machol RE. 1974. Mathematical methods in medical
diagnosis. Ann Biomed Eng 2:69 89.
Czajkowski JR. 1934. Preliminary report of archeological excava-
tions in Orleans Parish. Louisiana Conservation Rev 4:1218.
De Garine I. 1993. Culture, seasons and stress in two traditional
African cultures (Massa and Mussey). In: Ulijaszek SJ, Strick-
land SS, editors. Seasonality and human ecology. Cambridge:
University Press. p 184 201.
Degoulet P, Fieschi M. 1997. Introduction to clinical informatics.
New York: Springer.
Diamond GA, Forrester JS, Hirsch M, Staniloff HM, Vas R,
Berman DS, Swan HJ. 1980. Application of conditional proba-
bility analysis to the clinical diagnosis of coronary artery dis-
ease. J Clin Invest 65:1210 1221.
Diffey BL, Pal B, Gibson CJ, Clayton CB, Grifths ID. 1985.
Application of Bayes theorem to the diagnosis of ankylosing
spondylitis from radioisotope bone scans. Ann Rheum Dis 44:
667 670.
Du Boulay GH, Teather D, Harling D, Clarke G. 1977. Improve-
ment in the computer-assisted diagnosis of cerebral tumours.
Br J Radiol 50:849 854.
Edwards FH, Davies RS. 1984. Use of a Bayesian algorithm in the
computer-assisted diagnosis of appendicitis. Surg Gynecol Ob-
stet 158:219 222.
Elijovich F, Laffer CL. 1992. Bayesian analysis supports use of
ambulatory blood pressure monitors for screening. Hyperten-
sion [Suppl] 19:268 272.
El-Najar MY, Lozoff B, Ryan DJ. 1975. The paleoepidemiology of
porotic hyperostosis in the American Southwest: radiological
and ecological considerations. AJR Radium Ther Nucl Med
125:918 924.
Fryback DG. 1978. Bayes theorem and conditional nonindepen-
dence of data in medical diagnosis. Comput Biomed Res 11:
423 434.
Gammerman A, Thatcher AR. 1991. Bayesian diagnostic proba-
bilities without assuming independence of symptoms. Methods
Inf Med 30:1522.
Grauer AL, Stuart-Macadam P. 1998. Sex and gender in paleo-
pathological perspective. Cambridge: Cambridge University
Press.
Haddawy P, Kahn CE Jr, Butarbutar M. 1994. A Bayesian network
model for radiological diagnosis and procedure selection: work-up
of suspected gallbladder disease. Med Phys 21:11851192.
Horbar JD. 1983. Revising ranked probabilities: a Bayesian ap-
proach to incomplete knowledge. Comput Biomed Res 16:367
377.
Howe GM. 1997. People, environment, disease and death. Cardiff:
University of Wales Press.
Kahn CE Jr, Roberts LM, Wang K, Jenks D, Haddawy P. 1997.
Construction of a Bayesian network for mammographic diag-
nosis of breast cancer. Comput Biol Med 27:19 29.
 DIAGNOSIS USING BAYES THEOREM
Larsen CS. 1995. Biological changes in human populations with
agriculture. Annu Rev Anthropol 24:185213.
Ledley RS, Lusted LB. 1959. Reasoning functions of medical
diagnosis. Science 130:9 21.
Lind SE, Singer DE. 1986. Diagnosing liver metastases: a Bayes-
ian analysis. J Clin Oncol 4:379 388.
Lodwick GS, Haun DL, Smith WE, Keller RF, Roberston ED.
1963. Computer diagnosis of primary bone tumors: a prelimi-
nary report. Radiology 80:273.
Lovell NC. 2000. Paleopathological description and diagnosis. In:
Katzenbery MA, Saunders SR, editors. Biological anthropology
of the human skeleton. New York: Wiley-Liss. p 217248.
Lukacs JR, Walimbe SR. 1998. Physiological stress in prehistoric
India: new data on localized hypoplasia of primary canines
linked to climate and subsistence. J Archaeol Sci 25:571585.
Malchow-Moller A, Thomsen C, Matzen P, Mindeholm L, Bjerre-
gaard B, Bryant S, Hilden J, Holst-Christensen J, Johansen
TS, Juhl E. 1986. Computer diagnosis in jaundice. Bayes rule
founded on 1002 consecutive cases. J Hepatol 3:154 163.
Mani S, McDermott S, Valtorta M. 1997. MENTOR: a Bayesian
model for prediction of mental retardation in newborns. Res
Dev Disabil 18:303318.
McNeil BJ, Sherman H. 1978. Example: Bayesian calculations for
the determination of the etiology of pleuritic chest pain in
young adults in a teaching hospital. Part B. Comput Biomed
Res 11:187194.
Miettinen OS, Caro JJ. 1994. Foundations of medical diagnosis:
what actually are the parameters involved in Bayes theorem.
Stat Med 13:201209.
Miller E, Ragsdale BD, Ortner DJ. 1996. Accuracy in dry bone
diagnosis: a comment on paleopathological methods. Int J Os-
teoarchaeol 6:221229.
Montironi R, Bartels PH, Thompson D, Scarpelli M, Hamilton
PW. 1994. Prostatic intraepithelial neoplasia. Development of a
Bayesian belief network for diagnosis and grading. Anal Quant
Cytol Histol 16:101112.
Montironi R, Mazzucchelli R, Santinelli A, Hamilton PW, Thompson
D, Batels PH. 1998. Case diagnosis as positive identication in
prostatic neoplasia. Anal Quant Cytol Histol 20:424 436.
Norusis MJ, Jacquez JA. 1975. Diagnosis. I. Symptom noninde-
pendence in mathematical models for diagnosis. Comput
Biomed Res 8:156 172.
Nugent CA, Warner HR, Dunn JT, Tyler FH. 1964. Probability
theory in diagnosis of Cushings Syndrome. J Clin Endorcrinol
Metab 24:621 623.
Ohmann C, Yang Q, Kunneke M, Stoltzing H, Thon K, Lorenz W.
1988. Bayes theorem and conditional dependence of symptoms:
different models applied to data of upper gastrointestinal
bleeding. Methods Inf Med 27:73 83.
Ortner DJ. 1991. Theoretical and methodological issues in paleo-
pathology. In: Ortner DJ, Aufderheide AC, editors. Human
paleopathology: current syntheses and future options. Wash-
ington, DC: Smithsonian Institution Press. p 511.
Ortner DJ. 1992. Skeletal paleopathology: probabilities, possibil-
ities, impossibilities. In: Verano JW, Ubelaker DH, editors.
Disease and demography in the Americas. Washington, DC:
Smithsonian Institution Press. p 513.
Ortner DJ. 1994. Descriptive methodology in paleopathology. In:
Owsley DW, Jantz RL, editors. Skeletal biology in the Great
Plains. Washington, DC: Smithsonian Institution Press. p 73 80.
Ortner DJ, Putschar WGJ. 1981. Identication of pathological
conditions in human skeletal remains. Smithsonian contribu-
tions to anthropology, no. 28. Washington, DC: Smithsonian
Institution Press.
Overall JE, Williams CM. 1963. Conditional probability program
for diagnosis of thyroid function. JAMA 183:307.
Pastor A, Menendez R, Cremades MJ, Pastor V, Llopis R, Aznar
J. 1997. Diagnostic value of SCC, CEA and CYFRA 21.1 in lung
cancer: a Bayesian analysis. Eur Respir J 10:603 609.
Perpina M, Pellicer C, de Diego A, Compte L, Macian V. 1993.
Diagnostic value of the bronchial provocation test with metha-
choline in asthma. A Bayesian analysis approach. Chest 104:
149 154.
9
Phaneuf R, Hetu R, Hanley JA. 1985. A Bayesian approach for
predicting judged hearing disability. Am J Ind Med 7:343352.
Pollard T, Hyatt SB. 1999. Sex, gender and health. Cambridge:
Cambridge University Press. Poses RM, Cebul RD, Collins M,
Fager SS. 1986. The importance of disease prevalence in trans-
porting clinical prediction rules. The case of streptococcal phar-
yngitis. Ann Intern Med 105:586 591.
Powell ML. 1992. Health and disease in the late prehistoric
southeast. In: Verano JW, Ubelaker DH, editors. Disease and
demography in the Americas. Washington, DC: Smithsonian
Institution Press. p 4153.
Prince MJ. 1996. Predicting the onset of Alzheimers disease
using Bayes theorem. Am J Epidemiol 143:301308.
Reale A, Maccacaro GA, Rocca E, DIntino S, Gioffre PA, Vestri A,
Motolese M. 1968. Computer diagnosis of congenital heart dis-
ease. Comput Biomed Res 1:533549.
Roberts C, Manchester K. 1995. The archaeology of disease.
Gloucester, UK: Sutton Publishing.
Roberts C, Lucy D, Manchester K. 1994. Inammatory lesions of
the ribs: an analysis of the Terry collection. Am J Phys An-
thropol 95:169 182.
Rogers J, Waldron T, Dieppe P, Watt I. 1987. Arthropathies in
palaeopathology: the basis of classication according to most
probable cause. J Archaeol Sci 14:179 193.
Rothschild BM, Woods RJ, Ortel W. 1990. Rheumatoid arthritis
in the buff: erosive arthritis in deeshed bones. Am J Phys
Anthropol 82:441 450.
Russek E, Kronmal RA, Fisher LD. 1983. The effect of assuming
independence in applying Bayes theorem to risk estimation and
classication in diagnosis. Comput Biomed Res 16:537552.
Schell LM, Ulijaszek SJ, editors. 1999. Urbanism, health and
human biology in industrialized countries. Cambridge: Cam-
bridge University Press.
Sebes JI, Diggs LW. 1979. Radiographic changes in the skull in
sickle-cell anemia. AJR 132:373377.
Sherman H. 1978. A pocket diagnostic calculator program for
computing Bayesian probabilities for nine diseases with six-
teen symptoms. Comput Biomed Res 11:177186.
Siles S, Garrigues V, Ponce J, Galvez C, Berenguer J. 1997. Analysis
of the predictive value of clinical data in patients with suspected
colonic disease. Rev Esp Enferm Apar Dig 89:445 456.
Somogyi L, Cikes N, Marusic M. 1993. Evaluation of criteria
contributions for the classication of systemic lupus erythem-
atosus. Scand J Rheumatol 22:58 62.
Starmer CF, Lee KL. 1976. A mathematical approach to medical
decisions: application of Bayes rule to a mixture of continuous
and discrete clinical variables. Comput Biomed Res 9:531541.
Steinbock RT. 1976. Paleopathological diagnosis and interpreta-
tion. Springeld, IL: C.C. Thomas.
Van de Merwe JP. 1983. Differentiation between two diseases
using a programmable hand-held calculator and Bayes theo-
rem: application to Crohns disease and ulcerative colitis. Com-
put Biol Med 13:317332.
Vishnevskiy AA, Artobolevskiy II, Bykowskiy ML. 1973. Princi-
ples of a solution to the problem of diagnosis using digital
computers. In: AA Vishnevskiy, editor. Machine diagnosis and
information retrieval in medicine in the USSR. Bethesda, MD:
U.S. Department of Health, Education, and Welfare. p 113.
Waldron T. 1994. Counting the dead. The epidemiology of skeletal
populations. Chichester, UK: John Wiley & Sons.
Warner HR, Totonto AF, Veasey LG, Stephenson R. 1961. A math-
ematical approach to medical diagnosis. JAMAf 177:177183.
Warner HR, Totonto AF, Veasey LG. 1964. Experience with
Bayes theorem for computer diagnosis of congenital heart dis-
ease. Ann NY Acad Sci 115:558 567.
Whipple GH, Bradford WL. 1932. Racial or familial anemia of
children. Am J Phys Anthropol 44:336 365.
Worbel JS, Connolly JE. 1998. Making the diagnosis of osteomy-
elitis. The role of prevalence. J Am Podiatr Med Assoc 88:337
343.
Yan YY. 2000. The inuence of weather on human mortality in
Hong Kong. Soc Sci Med 50:419 427.
Zimmerman MR, Kelley MA. 1982. Atlas of human paleopathol-
ogy. New York: Praeger.