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International Journal of Paleopathology xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Paleopathology
journal homepage: www.elsevier.com/locate/ijpp
A ‘cold case’ of care: Looking at old data from a new perspective in mummy
research
⁎
Lorna Tilleya, , Kenneth Nystromb
a
b
Independent Researcher, Canberra, Australia
Department of Anthropology, State University of New York at New Paltz, USA
A R T I C LE I N FO
A B S T R A C T
Keywords:
Bioarchaeology of care
Mummy studies
Late Nasca
Tuberculosis
Pott’s disease
Nasca Boy
In 1973, analysis of the mummified remains of a young boy dated to 700AD and from the Late Nasca period
(Peru) identified (i) chronic Pott’s disease, leading to loss of lower body mobility, and (ii) acute miliary tuberculosis, affecting most organs and the immediate cause of death (Allison et al., 1973). This report was the first
to establish, beyond dispute, the presence of tuberculosis in the Americas before the arrival of Europeans. Here,
we revisit the ‘Nasca Boy’ from a bioarchaeology of care perspective. Contextualising the original study’s results
within what is known of contemporary lifeways, we apply the bioarchaeology of care methodology in considering the Nasca Boy’s experience of living with tuberculosis; the type of care he required and how this may
have evolved over a period of deteriorating health; and what such caregiving may suggest both about social
organisation within his community and some of the more everyday aspects of Nasca existence. Up to now, the
bioarchaeology of care approach has been employed almost exclusively with skeletal evidence; in this analysis of
the Nasca Boy’s remains, and in the accompanying wider-ranging discussion, we illustrate the potential of
preserved soft tissue evidence to contribute to research into disability and care in the past. Although this report
functions as a stand-alone case study, to obtain maximum benefit it should be read in conjunction with the
Introduction to the special International Journal of Paleopathology issue on ‘mummy studies and the bioarchaeology of care’ (Nystrom and Tilley, 2018).
1. Introduction
In 1973, Marvin Allison and colleagues analysed the mummified
remains of a young boy recovered from a single grave in Nasca
Province, Peru. These were radiocarbon-dated to 700AD and, in conjunction with the artefacts with which he was interred, identified him
as belonging to the final phase of the Nasca culture. For most of his life
this child faced increasing levels of health stress. Radiographic and
histological analyses of skeletal and preserved tissue elements reveal
both the presence of chronic Pott’s disease, likely acquired in early
childhood and resulting in loss of lower body mobility, and evidence of
miliary tuberculosis affecting most organs and leading to death (Allison
et al., 1973).
Allison et al.’s (1973) clearly-stated goal was to establish the presence of tuberculosis in the New World prior to European arrival. While
this emphasis on disease identification is unsurprising given the predominantly biomedical focus of mummy research (Nystrom, 2018), the
authors also include observations which hint at an interest in the subject’s life story going beyond diagnosis. Forty-five years on, with
⁎
growing acceptance that interpreting physical evidence from human
remains within its archaeological context can illuminate aspects of individual and culture that might otherwise be inaccessible (e.g. Buikstra
and Beck, 2006; Sofaer, 2006; Tilley, 2015a), the case of the ‘Nasca Boy’
lends itself to a wider range of questions than were originally asked of
it.
In the article introducing this special issue of the International
Journal of Paleopathology we argue that applying the bioarchaeology
of care approach (Tilley, 2015a) to mummified remains can increase
our understanding of the subject experiencing pathology and of their
lifeways, thereby enriching more traditional approaches in the field of
mummy studies (Nystrom and Tilley, this issue). We also argue that
evidence from preserved tissues may provide bioarchaeology of care
analyses with a type of information, and/or a level of detail in information, unavailable from skeletal materials alone. Putting both
propositions to the test in this paper, we take Allison et al.’s (1973) case
study content, together with findings from (bio)archaeological research
on Nasca lifeways and from clinical research on skeletal and non-skeletal tuberculosis and, assisted by the Index of Care (Tilley and
Corresponding author.
E-mail address: lorna.tilley@alumni.anu.edu.au (L. Tilley).
https://doi.org/10.1016/j.ijpp.2018.08.001
Received 1 May 2018; Received in revised form 30 June 2018; Accepted 4 August 2018
1879-9817/ © 2018 Elsevier Inc. All rights reserved.
Please cite this article as: Tilley, L., International Journal of Paleopathology (2018), https://doi.org/10.1016/j.ijpp.2018.08.001
International Journal of Paleopathology xxx (xxxx) xxx–xxx
L. Tilley, K. Nystrom
Cameron, 2014), work through the four stages of the bioarchaeology of
care methodology. Finally, we consider what broader lessons for
mummy research may be drawn from this exercise.
Firstly, some caveats. Allison et al.’s (1973) article is the sole substantive source of information about the subject of our study that we
have discovered. Although one of us (LT) has viewed the Nasca Boy’s
remains and his X-rays on display in the Regional Museum of Ica
‘Adolfo Bermúdez Jenkins’, Peru, and spoken briefly to the current
Museum Director about the exhibit, neither of us has physically inspected the remains, nor have we been able to find the initial records of
excavation or of subsequent laboratory examination. While not ideal,
this does not per se preclude bioarchaeology of care analysis. The
bioarchaeology of care is triggered by physical evidence suggesting
lived experience of disability, meaning that where there is a reliable
description of the subject’s remains, disease indicators present and diagnostic procedures undertaken - as exists in relation to the Nasca Boy a case study can be initiated on the basis of documentation alone (e.g.
Tilley, 2015b).
Failure to locate excavation details poses more of a problem, given
the scant background provided by Allison et al (1973). The context in
which a disease is experienced is often critical in determining its impacts. Without information about the subject’s immediate setting, we
are forced to extrapolate a lifeways context from a generalised depiction of life during the Late Nasca period. Although there is no reason to
believe this introduced any significant inaccuracy, a more detailed
context would have allowed a more sophisticated account of the subject’s life course.
Although this paper functions as a stand-alone report on a case of
caregiving in the past, for a fuller appreciation of what it seeks to
achieve - and why - it is best read in conjunction with the Introduction
to this special journal issue on ‘mummy studies and the bioarchaeology
of care’ (Nystrom and Tilley, 2018). Bioarchaeology of care analysis
identifies and interprets evidence for disability and health-related care,
and it is case study-based, contextualised and cross-disciplinary. Because the case study of the Nasca Boy assumes some familiarity with the
bioarchaeology of care, a brief overview of this approach and its webbased instrument, the Index of Care, is provided in Appendix A Supplementary Materials.
2. The Nasca Boy and the case for care: the results of
bioarchaeology of care analysis
The bioarchaeology of care approach comprises four stages of
analysis, each of which builds on the contents of preceding ones: the
first describes the subject, the evidence for disease, and the lifeways and
mortuary contexts; the second examines likely disease impact on health
and functioning, and assesses probable need for care based on this; the
third considers the features of care likely provided; and the fourth explores the implications of this care provision for new insights into the
care-recipient and their community (see Fig. 1, Nystrom and Tilley,
2018). This section reports the results of applying this methodology to
the evidence available in the case of the Nasca Boy.
Fig. 1. a and b: Two views of the Nasca Boy on display in the Regional Museum
of Ica, Peru (grave goods are visible in the background in image 1b).
Photographs by Lorna Tilley, with kind permission of the Museum Director,
August 2016.
2.1. Bioarchaeology of Care Stage 1: The subject and his context
the Nasca Boy’s remains were first exhibited, adds llama ears and hoof,
a guinea pig and a bowl made from a gourd to this list. In addition, the
museum exhibit itself includes a set of panpipes, a baton, a woven strap,
and the textiles in which he was wrapped (Fig. 1).
While not mentioned in the original article by Allison et al. (1973),
examination of the lateral X-ray of the boy’s head on display in the
Museum (LT) suggests he underwent fronto-occipital cranial modification; this practice was very common in Nasca culture, with studies recording the procedure, interpreted as a marker of social identity, in well
over half of all skulls recovered and across all burial categories (e.g.
Browne et al., 1993; Carmichael, 1988:183-184, 291; Silverman and
In 1970, a fardo funerario (‘mummy bundle’) containing the wellpreserved remains of a boy aged between 8 and 10 years and dated to
around 700AD was recovered from an undisturbed grave in Hacienda
Agua Salada, Nasca Province, Peru. Within the bundle, the child was
seated on a cushioned adobe stool, with knees bent and feet drawn back
beneath him. The mummy bundle was accompanied by various grave
goods. Allison et al. (1973:986-987) note “a [ceramic] bottle, dish, and
paint pot containing ochre”, “a feathered ornament decorated with
condor feathers” and a “turban with macaw feathers … designat[ing]
him as a person of importance.” At the Regional Museum of Ica an
undated museum placard next to the mummy, probably produced when
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L. Tilley, K. Nystrom
standing” (Allison et al, 1973:991; Gerszten, 2018).
The date of 700 AD places the Nasca Boy in the early Middle
Horizon, at the tail-end of the Late Nasca and overlapping the rise of
Wari imperialism. This was a time of uncertainty, driven by the interrelated and escalating effects of worsening environmental conditions,
changes in social organisation and settlement patterns, and increasing
population health stress (e.g. Buzon et al., 2012; Conlee, 2014; FehrenSchmitz et al., 2014; Proulx, 2007a). The following section offers a
context for considering what the needs of a child suffering a chronic and
unremitting disease may have comprised, how these needs might have
been met, and what motivated the care the Nasca Boy appears to have
received in life and after death.
Proulx, 2002:68-70) Also unmentioned by Allison et al. (1973), the
museum placard reports a height measurement of 1.07 m for the Nasca
Boy.
Allison et al. (1973) reported skeletal and soft tissue evidence from
the boy’s remains revealing the presence of pulmonary and extrapulmonary tuberculosis. Kyphosis and scoliosis were present in the
lumbar region, and X-rays showed tuberculosis of the spine (Pott’s
disease) involving lumbar vertebrae 1, 2 and 3 and fusion of at least two
vertebrae. A psoas abscess measuring approximately two inches in
diameter and in direct contact with vertebrae was found on autopsy,
and removal of dried pus exposed severe erosion of adjoining bone and
intervertebral disc. Macroscopic examination revealed tubercle-like
lesions in the right lung and surface of the pleura, the liver and right
kidney, and histological analysis of tissue sections established the presence of acid-fast bacilli in these sites as well as disclosing small tubercles and bacilli in the heart and pericardium. These latter findings
resulted in the diagnosis of miliary tuberculosis. Radiography also revealed multiple Harris lines; the seven Harris lines recorded on the right
tibia were estimated as occurring between the ages of 1.7 and 6.5 years,
and in a later publication Allison describes these as ‘the largest number
of lines seen [in remains] at any one site’ (Allison et al., 1974:413).
Allison et al. (1973) conclude that, towards the end of his life, the
subject experienced paraplegia consequent on Pott’s disease. It is at this
point that the authors step outside the strictly biomedical realm and
into the sphere of cultural interpretation. They describe the cushioned
adobe stool on which the boy was placed as being “contoured to fit his
body”, observing that “[t]his burial position was most unusual and,
with the seat and cushion, led to the belief that this seat was used by the
child during life” (Allison et al., 1973:986). Further, the authors note
that “the position of [his] legs was that commonly seen in persons who
are paralyzed in the lower limbs and unable to walk” (Allison et al.,
1973:986). Finally, they refer to a still extant practice in parts of South
America in which “crippled persons” are seated, during life, in a similar
position to that of the Nasca Boy in death (Allison et al., 1973:987,
Fig. 2), and suggest that the “use of the ‘orthopaedic’ seat leads to the
assumption that the disease [giving rise to this condition] was long-
2.1.1. The context of care: the Late Nasca
Location and environment
Hacienda Agua Salada is located on the eastern side of the Rio
Nasca, a tributary of the Rio Grande, situated approximately 40 km
inland from the coast and 230 m above sea level (Fig. 2). It is around
20 km downstream from Cahuachi, once the principal ceremonial
centre of Nasca culture, but which had lost its prominence by the Late
Nasca (Silverman, 2002). The landscape comprises strips of vegetation
(‘oases’) along the river, bounded by sterile desert extending eastward
to the Andean foothills (Orefici and Rojas, 2016). The past climate was
similar to today’s, with low humidity, a temperature range of 5 ° to 30 °
Celsius, and precipitation of less than 1 mm per annum (Orefici and
Rojas, 2016; Proulx, 2007a). Proulx (2007b: 42), in his survey of the
lower Rio Nasca and the Rio Grande, characterizes Hacienda Agua
Salada as a “small settlement … [near a] … giant cemetery … that
contains graves from several cultural periods.” It is unclear whether the
child’s remains were recovered from within the settlement or from the
cemetery itself, but both would be consistent with Nasca mortuary
customs (Buzon et al., 2012; Kroeber and Collier, 1998; Proulx, 2006,
2007b).
Economy and social organisation
The Nasca economy was primarily based on crops (maize, potatoes,
squash, beans, yucca, native fruits, cotton) and livestock (llama, alpaca,
Fig. 2. Location and landscape of Agua Salada, Peru (Google Maps).
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L. Tilley, K. Nystrom
differentiation, but ‘wealthy’ burials during the Middle Nasca may indicate growing social stratification, and during the Late Nasca competition for diminishing resources likely led to further inequality (Conlee,
2014; Kellner and Schoeninger, 2008; Proulx, 2006, 2007a). There is no
evidence that these changes affected lifeways in smaller settlements
such as Hacienda Agua Salada, however. During the Middle Horizon,
Nasca lands were absorbed into the Wari empire, but despite pockets of
resistance it is likely the transition was realised through assimilation
rather than violent conquest (Whalen et al., 2013). The process of imperial incorporation was well underway by the time of the Nasca Boy,
but again, it is unlikely to have had a substantive impact on Hacienda
Agua Salada daily life.
Health
The health impacts of intensifying environmental pressures and
social and political change may be recorded in Nasca human remains.
From 600AD onwards, increasing rates of cribra orbitalia, porotic hyperostosis, linear enamel hypoplasia and non-specific periostitis would
appear to indicate deteriorating population health (Blom et al., 2005;
Cagigao, 2009). Although data are limited, they suggest that in the
Early-Middle Nasca, the infant mortality rate was around 35 per cent,
declining to around 2 per cent by age 7, but that between 600–1100 AD
infant early childhood mortality had increased significantly and
average life expectancy reduced from 38 to 43 to 31 to 36 years, with
mortality rising across all age groups (Blom et al., 2005; Cagigao,
2009). Data indicate an increased frequency of inflicted injury during
the Late Nasca (Arkush and Tung, 2013), although this is from a low
base, sample sizes are small, and it is unclear whether this was the
result of opposition to Wari expansion, an outcome of inter-group
competition for diminishing resources, or the product of intra-group
tensions arising from lifeways disruption. Regardless, evidence for an
increase in interpersonal violence adds to the picture of people living
with stress and uncertainty. With regard to specific diseases, pre-Columbian mummy and skeletal remains from the Peruvian south coast
and the adjoining Chilean north coast evidence pathologies ranging
from pulmonary and cardiovascular disease to viral, fungal and parasitic infections (e.g. Arriaza et al., 1995; Aufderheide et al., 2002, 2004,
2008; Gabrovsky et al., 2016; Gerszten et al., 2012). Since Allison
et al.’s (1973) report, there has been repeated confirmation of the
presence of tuberculosis in pre-Columbian South America. Arriaza et al
(1995) propose that by the first millennium AD up to one-third of those
in Andean agropastoral communities had contracted tuberculosis
during their lifetime; Gómez i Prat and Souza (2003) conclude that
2000 years ago tuberculosis was endemic along the west coast of South
America; and Lombardi and Caceres (2000) calculate that by 900AD
disease prevalence in the Peruvian south coast population was one in
ten.
Mortuary practice
The Nasca Boy was wrapped in textiles and, according to the museum placard, was interred as a single burial in an unlined pit measuring 230 cms deep by 90 cms wide (Fig. 3). This treatment conforms
to Nasca mortuary tradition, in which pit graves, usually containing
only one individual, were the most common category of burial
throughout all phases of the Nasca culture, and comprised over 30% of
interments (Isla and Reindel, 2006:380; Kroeber and Collier, 1998;
Silverman, 2002:195ff). All goods included with the boy’s remains are
typical of those found in Nasca graves (including the feathered turban
singled out by Allison et al., 1973; Carmichael 1988:271ff, 495-497;
Conlee, 2007; Kroeber and Collier, 1998; Proulx, 2006, 2007a;
Silverman and Proulx, 2002) and, more particularly, in the graves of
Nasca children and infants (Kroeber and Collier, 1998) with the exception of the panpipes. This instrument, caches of which have been
recovered from ceremonial sites, is usually interpreted in terms of ritual
paraphernalia associated with shamanic practices, pilgrimage, ceremonies and festivals, and is frequently represented in these contexts on
Nasca pottery (Proulx, 2000, 2006; Silverman, 1993:331-339). It has
been suggested that, in the Early Nasca at least, panpipe distribution
Fig. 3. Schematic of the Nasca Boy’s mortuary context, displayed in the
Regional Museum of Ica, Peru. This graphic depicts a selection of grave goods
around the mummy bundle: (clockwise, from top right) guinea pig, yucca,
maize, llama foot, vase/vessel (pottery), bowl (pottery), effigy jar (pottery),
gourd bowl, llama ear. Photograph by Lorna Tilley, with kind permission of the
Museum Director, August 2016.
guinea pig) and included involvement in coastal and inland trading
networks; other economic activities included lithics, textiles and ceramics manufacture, the first two of these, at least, usually undertaken in
a domestic context (Conlee, 2014; Proulx, 2007a,b; Whalen,
2014:329ff). Agriculture was reliant on water from snow melt and
summer rains in the Andes (Orefici and Rojas, 2016; Proulx, 2007a).
Beginning around 640AD, greater climatic variability resulted in periods of drought and encroaching desertification, increasingly marginalising production and undermining social stability (Conlee, 2014; Eitel
et al., 2005; Fehren-Schmitz et al., 2014; Orefici and Rojas, 2016).
Settlements were unfortified, ranging from self-sufficient hamlets,
through larger villages, to formally laid-out ‘civic-ceremonial’ sites
serving as religious and cultural centres and capable of housing large
numbers of people (Conlee, 2014; Proulx, 2007a,b; Van Gijseghem and
Vaughn, 2008). Domestic architecture reflects diversity in design and
construction between settlements, with variations likely reflecting independent groups (Conlee, 2014; Proulx, 2006:4-7; Silverman, 2002).
Although a trend to aggregation into fewer and larger settlements in
response to Late Nasca environmental and related social pressures has
been proposed (Arkush and Tung, 2013; Kellner and Schoeninger,
2008), Proulx (2007b) recorded only smaller settlement sites along the
Rio Nasca and Rio Grande. Hacienda Agua Salada was probably typical
of hamlet communities in this area.
The basic unit of society was very possibly the ayllu, a form of precolonial Andean social organisation based on membership of an extended family (defined by possession of a common ancestor) with collective ownership of land and shared civic and/or religious responsibilities (Baca et al., 2012; Silverman, 1993: 308-312). Although there is
no consensus on this point (e.g. Isbell, 1997) it makes sense; the internal
cohesion characterising the ayllu would make farming a progressively
marginalised landscape a more viable undertaking. The Nasca initially
operated as a ‘middle-range society’, with low levels of status
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L. Tilley, K. Nystrom
little written on the mental health impacts of paediatric tuberculosis
specifically, research into children’s experience of living with chronic
disease (general and specific) suggests possible psychological impacts
include depression, anxiety, grief and disengagement (Compas et al.,
2012, 2014; Flint pers. com., 2016). The presence of multiple Harris
lines, primarily associated with interruptions to growth associated with
malnourishment (Beom et al., 2014; Geber, 2014), provides indirect
support for the proposal that this young boy lived in a state of health
stress for most of his childhood. Given prevailing environmental conditions it is very likely the Hacienda Agua Salada community faced
periods of nutritional hardship, but the number of Harris lines in the
Nasca Boy’s remains suggests particular problems with ingestion and/or
absorption of nutrients, and this reading fits well with symptoms of
Pott’s disease.
At least 50 per cent of modern individuals with later stage Pott’s
disease experience disabling neurological sequelae arising from compression of the spinal cord, including impaired sensation, activity limiting pain, paresis, and paraplegia (Agrawal et al., 2010; Benzagmout
et al., 2011; Hidalgo, 2016; Vadivelu et al., 2013). Taking into account
both the extent of vertebral and intervertebral disc destruction evident
in the Nasca Boy’s remains (Allison et al., 1973), and the ethnographic
evidence of the adobe stool, it is plausible that the subject suffered
effective, even if not total, loss of lower body mobility for some time
before his death - a period that minimally lasted long enough to require
an “orthopaedic seat”. Even very short periods of immobility are accompanied by a raft of potential challenges to metabolic, respiratory,
cardiovascular, gastrointestinal and integumentary health, as well as to
psychological well-being (Olsen et al., 1967; Tilley, 2015a: 199ff). The
Nasca Boy, with his already compromised immune system, would have
been vulnerable to any and all of these.
As with Pott’s disease, non-specific symptoms of military tuberculosis include fevers, chills, night sweats, weakness, fatigue, anorexia
and weight loss. Precise signs and symptoms depend on which organs
are implicated in disease, but frequently include confusion, seizures,
neurological deficit, generalised lymphadenopathy, multiple organ
dysfunction and/or failure, and coma (Golden and Vikram, 2005;
Herchline, 2015; Lessnau, 2015). Untreated miliary tuberculosis is invariably fatal, and when an individual is already health-compromised,
survival time is measured in weeks rather than months (Lessnau, 2015).
In his weakened state, it is probable the Nasca Boy survived only a very
short time (possibly only days) once miliary infection was established.
In summary, a conservative scenario sees the Nasca Boy undergoing
a primary and unremarkable infection in late infancy; entering childhood facing the increasingly debilitating and eventually immobilising
impacts of Pott’s disease; and finally, having survived to around 8 years
of age, succumbing to a widespread and overwhelming miliary tuberculosis rapidly leading to death.
was restricted, and when found in domestic and (occasionally) mortuary sites was associated with high status households (Vaughn, 2004).
The most significant irregularity in the Nasca Boy’s mortuary
treatment is the positioning of his remains within the bundle. Most pit
burial remains were positioned with knees drawn up to the chest and
arms wrapped around the knees, or, less often, were laid on their side
with legs slightly flexed (Carmichael, 1988:189; Conlee, 2007; Isla and
Reindel, 2006); both postures thought to mimic positions assumed
while alive (Rowe, 1995:28, cited Conlee, 2007:442). As earlier described, the subject’s remains had been manipulated to present him
squatting on a cushioned, contoured, adobe stool likely used in life.
Allison et al. (1973:986) describe this arrangement as “most unusual”.
As far as we are aware it is unique.
Iconography
The rich Nasca iconography decorating pottery and textiles informs
our understanding of this culture. It suggests Nasca cosmology involved
animist beliefs in the supernatural forces of earth, sky, and sea as
controllers of human destiny; a ritual emphasis on (agricultural) fertility, death, and regeneration, which might include symbolic or actual
sacrifice (decapitation) involving shedding and scattering of blood; and
that religious leaders, including shamans, were an elite group (e.g.
Carmichael, 1994; Conlee, 2014; Proulx, 2006, 2007a; Vaughn and
Grados, 2006). As Proulx points out, however, ‘[m]ost interesting is
what is not depicted in the art’ (Proulx, 2000:13, emphasis in original).
The thousands of images available provide no insight into ordinary life
– there are no domestic scenes, very few representations of women, and
no representations of children (Proulx, 2000, 2006).
One of the most noteworthy contributions of the bioarchaeology of
care study of the Nasca Boy is that it offers a point of entry for thinking
about some of the more mundane aspects of Nasca existence.
2.2. Bioarchaeology of Care Stage 2: Clinical impacts and implications for
function
2.2.1. Clinical impacts
Allison et al (1973) posit a clinical history in which the Nasca Boy
suffered a relatively mild, primary pulmonary infection between the
ages of one and two years, likely corresponding to the earliest of the
Harris lines. Following this, “[i]ncipient Pott’s disease must have developed at an early age, and renal tuberculosis some time later. The
terminal event was a hematogenous spread with extensive miliary
disease” (Allison et al, 1973:990-991).
The clinical literature on paediatric tuberculosis supports this
timetable (Batra, 2015; Benzagmout et al., 2011). The initial episode
likely resulted in haematogenous spread of tubercular bacilli to the
spine, with active onset of Pott’s disease most probably following soon
after. The spread of tubercular bacilli to extrapulmonary organs may
have occurred simultaneously, and in this case the bacilli may have
remained dormant for some years until reactivated by a particular
health challenge. Alternatively, widespread infection may have been
the result of a later dissemination of bacilli originating at the site of the
spinal pathology (Agrawal et al., 2010; Batra, 2015; Benzagmout et al.,
2011; Lessnau, 2015).
Initially, signs of Pott’s disease may be insidious and non-specific;
untreated, symptoms increase in intensity and impact over a period of
years (Benzagmout et al., 2011; Flint pers. com., 2016; Hidalgo, 2016).
This likely describes what occurred in the case of the Nasca Boy. The
signs and symptoms of Pott’s disease in children include back and chest
pain, fever and night sweats, anorexia and weight loss, reduced energy/
exhaustion, generalised weakness and failure to thrive, a compromised
immune system, bowel and bladder dysfunction, and increasing vulnerability to respiratory disease associated with mechanical restrictions
of spinal pathology, and all children with spinal tuberculosis will
manifest some (although not necessarily all) of these (Agrawal et al.,
2010; Benzagmout et al., 2011; Eisen et al., 2012; Hidalgo, 2016;
Nussbaum et al., 1995; Vadivelu et al., 2013). Although there has been
2.2.2. Functional implications
The trajectory of the Nasca Boy’s lifecourse would be shaped by the
trajectory of his disease. In broad terms, the day-to-day impact of pathology on his functioning capability can be described with confidence.
He would become progressively weaker, presenting as the classic ‘sickly
child’ from an early age. If onset of Pott’s disease occurred in late infancy or early childhood, as seems probable, the demands of living with
systemic symptoms - fevers, chills, anorexia, weight loss, exhaustion,
reduced immunocompetence - would likely lead to delays in motor
skills development, and this, in turn, would affect cognitive, emotional,
and social development (see CDC, 2017 for developmental milestones).
There can be no doubt that as the Nasca Boy progressed through
childhood, and well before loss of lower body mobility, he would be
unable to keep pace physically with his peers. In practice, this would
mean exclusion, in part or whole, from many of the unscripted activities
(play, exploration, experimentation) in which children typically engage
and through which they learn social and applied skills (Baxter, 2005;
Qamar, 2015). Further to this, ethnographic research in pre-industrial
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L. Tilley, K. Nystrom
envisage the Nasca Boy’s survival without sustained healthcare provision.
In this period, palliative treatment was the only option for tuberculosis. The boy’s care would involve caregivers comforting him
when he was in pain or kept awake with night sweats; cooling (or
warming) him when he suffered fevers (or chills); producing nutritious,
easily digested meals to encourage appetite and provide nourishment,
and coaxing him to eat these; and vigilance in monitoring general
health status, physiological function and physical safety. As disease
progressed, care requirements would increase accordingly. With developing cognitive awareness the Nasca Boy would become more conscious of restrictions, potentially leading to depression and/or anxiety.
He would need considerable social support in addition to hands-on
nursing care - company to keep him stimulated, entertained and distracted, and motivated to cope with health-dictated limitations.
Although the Hacienda Agua Salada community were almost certainly
familiar with plants with medicinal and/or psychoactive properties,
available locally and through Nasca trading networks (coca, for example, was known to the Nasca [Silverman and Proulx, 2002:54-55;
Valdez and Valdez 2017]), and although it is very likely that plant remedies were employed to relieve symptoms such as pain, lack of appetite, high temperature, fatigue, psychological depression, respiratory
and gastrointestinal disorders (see e.g. Bastos et al., 2007; Biondich and
Joslin, 2016; Brown, 2014; Bussmann and Sharon, 2006; Mendoza,
2003; Torres, 1995; Weil, 1981), there is no actual evidence that such
treatments were used. In saying this, it must be noted that no such
evidence was actively sought; as later discussed, this failure may represent an avenue for future research.
Loss of lower body mobility would demand an escalation of care.
Increased vulnerability to health challenges would require closer
monitoring of health status to enable rapid response - for example, to
control fluctuations in body temperature, to ensure adequate fluid intake, to maintain hygiene, to check for wounds. The Nasca Boy would
require physical therapy, such as massage and regular repositioning, to
assist with various areas of body system functioning (circulation, digestion, respiration) as well as to minimise risk of pressure sores (Tilley,
2015:204-209 and references therein). In addition to the inference of
nursing care there is a more material clue: the adobe stool, which
Allison et al. (1973) suggest was used in transporting the Nasca Boy
during the latter part of his life. It is not clear how the stool was used whether the child was transported on the stool itself, enabling him to
retain an upright position during portage, or whether the child and the
stool were carried separately, with the stool providing a custom-made
support on reaching the destination. Either way, the stool speaks of an
understanding and an acceptance of the Nasca Boy’s needs, and of the
readiness to work around them.
The Nasca Boy’s experience of miliary tuberculosis was a systemwide attack on an already failing young body. The only response
available to his carers was round-the-clock nursing; given the care he
received though his years of living with disease, he most probably also
received whatever care was practicable in his last days.
We can only speculate about the identity of the Nasca Boy’s caregiver(s). It is automatic to assume that birth-mothers are the primary
carers of infants, but it is common practice in subsistence societies for
older children (siblings and others), and/or older adults no longer
capable of heavy labour, to take responsibility for looking after children
when weaned, freeing mothers for participation in more economically
productive work (Baitzel, 2018; Qamar, 2015). Halcrow and Tayles
(2008) propose a theoretical model that combines social, biological and
chronological age for assessing what constituted ‘childhood’ in past
populations. Accepting that these three variables are inextricably related in determining the way any child is perceived within their immediate family and wider community, it is postulated that the increasing biological frailty of the Nasca Boy, along with his reduced (and
inexorably reducing) ability to take part in physical activity, consigned
him to a younger, more dependent, social category than would
and/or subsistence agricultural societies indicates that even young
children are usually expected to undertake work that contributes - often
quite substantially - to the group economy (Baxter, 2005; Kamp, 2001).
Children’s labour is also considered integral to their socialisation, and
“[i]n agrarian societies and in rural settings, children are … [understood as] social actors with their own agency …” (Qamar, 2015: 102).
In modern rural Bolivia, Punch (2001) documents children from the age
of three years onwards performing domestic and agricultural chores
such as feeding stock, scaring birds away from crops, collecting water
and firewood. Based on ethnographic and ethnohistorical evidence,
Baitzel (2018) suggests similar childhood practices in Andean Tiwanaku society (500–1100AD) and, while writing considerably after the
Tiwanaku period, the descriptions of children’s roles by the Quechuan
chronicler Guamán Poma (1615 [2009]) leave no doubt that Inkan
youngsters were also obliged to carry out well-defined, age-appropriate
tasks in and around the home.
While lacking direct information on children’s place in Nasca society, and recognising that social roles of children will vary across time
and culture, it seems reasonable to presume that expectations similar to
those outlined above applied to children in Late Nasca lifeways1. Although the Nasca Boy may have been capable of undertaking light
duties until the effects of disease became incapacitating, he was probably never strong enough to take on a ‘normal’ workload (in the sense of
the workload ‘normal’ for his chronological age). All the above would
have implications for the way he was perceived and accommodated
within his immediate family and his wider social circle and, in turn, for
the development of the Nasca Boy’s personal sense of identity.
As the Nasca Boy lost lower body mobility, the ability to perform
many of the activities essential to independent functioning in daily life
would radically diminish (Katz, 1983; Tilley, 2015a:165–166). He
would find it difficult, if not impossible, to adequately bathe and toilet
himself; he would be dependent on others to ensure food and fluids
were within reach2; and although he might be able to use upper body
strength to navigate his immediate vicinity he would be incapable of
independent movement over any greater distance, resulting in increased reliance on others for social interaction opportunities. Finally,
when suffering the catastrophic effects of disease during the brief
period between miliary tuberculosis onset and death, the Nasca Boy
would be incapable of almost all independent actions, leaving him
wholly dependent on his caregivers.
2.3. Bioarchaeology of Care Stage 3: Modelling care provided to the Nasca
Boy
In bioarchaeology of care analysis, ‘care’ signifies the response to a
specifically health-related condition. Deriving a model of the care provided involves identifying what responses would be required to address
likely impacts of pathology, and which of these responses might be
feasible within the contemporary lifeways setting. When ‘care’ is used
in relation to a child, however, it can be conceptually difficult to make
the distinction between what health-related caregiving comprises and
the normal nurturing that all infants and young children require for
their development (Oxenham and Willis, 2017). In this particular case,
ignoring the unarguable requirements for care provision associated
with eventual paraplegia, the impact of Pott’s disease symptoms would
have required an increasing amount of health-related caregiving - i.e.
care exceeding that normally entailed in child-rearing - from around
age two and lasting for up to six years or more. It is not possible to
1
Most social archaeological research specific to children’s role in the PreColumbian Andes focusses on aspects of child sacrifice and/or covers cultural
periods considerably later than the Nasca, and thus provides no basis for more
definitive extrapolation.
2
While it can be argued that all children are dependent on others for sustenance, mobile youngsters can actively seek out supplies.
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International Journal of Paleopathology xxx (xxxx) xxx–xxx
L. Tilley, K. Nystrom
rewarding, if only because it prompts us to think about the motivations
of those involved in the burial ceremony. In this case, there are a
number of plausible (and by no means mutually exclusive) hypotheses
for the panpipes’ presence. These include the instrument’s association
with shamanic practices and so, potentially, with healing or spiritual
rituals relevant to the Nasca Boy in the afterlife; its role in ceremonies
and festivals - perhaps it represented memories of events enjoyed by the
child during life; and/or perhaps the Nasca Boy loved music - possibly
he played himself (a sedentary activity available where others were
denied) and the panpipes in his grave once belonged to him. While it is
impossible to assert that any one explanation is ‘correct’, running
through all of them is a common theme directly relevant to this analysis: each option canvassed revolves around a material acknowledgement of the special nature of the Nasca Boy by those responsible
for his interment3.
The more intriguing departure from traditional practice lies in the
unique arrangement of the young boy’s remains - posed on his stool in a
position likely adopted during life, particularly in social settings. This
feature of mortuary treatment can be approached at two levels: in terms
of Nasca beliefs about what followed corporeal death, and in terms of
the regard felt for the Nasca Boy by those burying him.
In relation to the former, it has been proposed that the funerary
treatment of remains - their location, orientation, and/or disposition, as
well their accompanying grave goods - embodies a culture’s spiritual
and cosmological beliefs (Carr, 1995), and that variations to standard
practice may indicate that an individual was perceived, and possibly
treated, as ‘different’ or ‘deviant’ when alive (Fay, 2009; Shay, 1985;
Weiss-Krejci, 2008). In this instance, inclusion of an item important to
enabling aspects of the living subject’s social participation as an integral
component of his burial suggests a belief he would have some need for
it - either to assist in passage to the afterlife, and/or in the afterlife
itself. In turn, this suggests a cultural belief in continued existence after
death for most, if not all, members of Nasca society, regardless of social
position (as previously discussed, there is no evidence to indicate the
Nasca Boy belonged to an elite class) or health status. Retention of the
posture assumed during life may reflect a belief that for part, if not the
whole, of this existence the deceased retained the physical attributes
present at death.
The more straightforward interpretation of burial evidence is that
the Nasca Boy occupied a privileged position in the affections of his
carers and his community. It would have been an easy matter to prepare
his body in the customary manner - knees flexed to chest (Conlee, 2007;
Isla and Reindel, 2006). While wrapping him in a squatting position
required only a marginal amount of extra work, ensuring preparations
for his interment corresponded to features of his living circumstances
suggests a measure of special consideration. That this effort was made
might merely reflect the demands of cultural practice (see above), but
this extension of care given to the living child may also represent a
more intimate manner of marking his passing4.
normally correspond to his chronological age. We have little information about Nasca weaning practice (Webb et al., 2015), but if the Nasca
Boy’s symptoms manifested in early childhood he was probably weaned
by this stage. In this scenario, it is likely that responsibility for the
Nasca Boy’s health-related care requirements was shared between his
immediate family and others (children and adults) who may have been
related to him primarily through shared group - ayllu? - membership.
2.4. Bioarchaeology of Care Stage 4: Extracting insights from the provision
of care
Tuberculosis was well-established in South America by the Late
Nasca (Arriaza et al., 1995; Lombardi and Caceres, 2000; Gómez i Prat
and Souza, 2003), so we can assume that most communities were, to
some degree, familiar with its symptoms, progression, and possible
outcomes. Whether tuberculosis was recognised as a single, specific
disease by the population of Hacienda Agua Salada and, if so, how it
was interpreted in terms of causation and consequence, and whether it
was identified as responsible for the Nasca Boy’s condition, is impossible to say. Yet however his condition was explained by those
tending him, that it was irreversible would be apparent quite some time
before he died - plainly at the onset of lower body paralysis, but possibly during the long period of decline before paralysis occurred. The
Nasca Boy’s care may have been initiated in anticipation of recovery,
but it was continued when likelihood of recovery was remote. Such
caregiving provides an opportunity to reflect on aspects of social
practice within his community and, more generally, on how children
may have been regarded within Nasca culture.
When infant mortality is very high, there may be a substantial investment of effort and emotion in achieving a child’s survival through
this perilous first phase of life (Baitzel, 2018; Golden, 1988; LeVine and
Levine, 1996). Having reached this milestone to then be confronted
with a child who was becoming increasingly frail and sickly would call
for an extended, and likely expanded, outlay of both. The Nasca Boy’s
survival suggests this particular child was sufficiently loved and prized
for those responsible for looking after him to make this commitment.
Extrapolating from the individual to the collective, there is no reason to
suppose that all children were not equally valued.
The Nasca Boy’s care, however well managed, would inevitably
impose costs on a small, economically and environmentally vulnerable
community. Long term care for a child suffering serious chronic disease
is not just an exercise in meeting clearly defined physical needs, but
involves meeting psychological needs as well, and in later phases of
illness both aspects of caregiving consume increasing time and energy.
Whether caregiving was predominantly undertaken by a single individual, or shared between many, at some level successful care provision would involve ongoing adjustments to ‘normal’ work and family
activities. In an era of declining population health (Blom et al., 2005;
Cagigao, 2009) caregiving may have been a comparatively commonplace behaviour; nevertheless, provision of care to a youngster unlikely
to survive to adulthood, who would never be able to reciprocate this
care, adds weight to the inference that this was a society in which
children, healthy or otherwise, were treasured.
The detail of the Nasca Boy’s burial provides support for this proposition. Neither grave goods nor any reported feature of the funerary
pit itself place this burial in an ‘elite’ category, suggesting that he received burial rites on the same basis as would any other member of
Hacienda Agua Salada society. However, as described earlier (Section
2.1), there are two interesting anomalies in his mortuary treatment.
The first anomaly, the inclusion of panpipes, may seem immaterial,
but all grave goods are intentional deposits and therefore have meaning
- symbolic, emotional or practical, major or minor - for those who
placed them in the burial. These items may also have had special
meaning for the deceased during their lifetime. Although interpretation
of this meaning is problematic for archaeologists (e.g. Hodder and
Hutson, 1986; Parker Pearson, 1982, 1999), speculation can be
3
In an interesting reversal of Nasca practice (see Section 2.2, Mortuary),
Baitzel (2018) found that in Tiwanaku society (500–1100 AD) panpipes were
only deposited in children’s graves, and suggests that in this culture children
may have been the accredited musicians. She proposes a very similar hypothesis
on the role of panpipes as a grave offering however - panpipes “could have
presented mourning parents with the opportunity to recognise specific attributes of the deceased” (Baitzel, 2018: 195).
4
It is interesting to note that Man Bac Burial 9, the severely disabled subject
of the first bioarchaeology of care case study who received around a decade of
intensive caregiving (Tilley and Oxenham, 2011), was also interred in a way
which distinguished him from others in the same cemetery. It was concluded
that his anomalous burial disposition likely constituted acknowledgment of his
special physical and/or spiritual needs and limitations (see Tilley, 2015a).
7
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L. Tilley, K. Nystrom
3. Discussion
signatures associated with the metabolism of drugs and alcohol (e.g.,
Balabanova et al., 1994; Cartmell et al., 1991); for example, Cartmell
et al. (1991) suggest that evidence for coca ingestion during the last few
weeks of life, found in the hair of children from pre-Columbian Chile,
may reflect a therapeutic function. More recently, researchers are examining cortisol levels in mummy hair to reconstruct a subject’s stress
response over a period of disease experience (see Brown and Wilson,
2018; Webb et al., 2010, 2015; Wilson and Tobin, 2010).
Of course, it is possible that these ‘missed opportunities’ might still
be exploited. Although almost half a century has passed, the original
report of the Nasca Boy’s excavation is probably lost rather than destroyed, and if retrieved might add valuable detail to the broader
context in which this current study locates its subject. It is unclear if
Allison and colleagues removed the entire “dried, necrotic mass of
tissue” that contained the intestines and stomach of the Nasca Boy, but
it is conceivable that portions of these organs remain in situ and
amenable to analysis. Finally, the Nasca Boy’s hair remains intact.
Given that this hair is approximately 10–12 cm s in length (visual estimate - LT), and that 1 cm of hair roughly equates to one month of
growth (e.g. Webb et al., 2015:31), its study - together with that of any
abdominal materials - may allow us to address questions of physiological and psychological health status, diet and, possibly, ‘medicinal’
treatments during the last 9–11 months of the Nasca Boy’s life.
At first glance, the conclusion that people in the past cherished their
children, providing sometimes costly care when disease struck, hardly
constitutes a major revelation. It takes on a greater significance, however, when we consider how little is known of everyday Nasca behaviour. Archaeological research on Nasca culture has concentrated on
the big questions - cultural phases and transitions, modes of governance, monumental architecture, interpretation of iconography, details
of artefact manufacture, agricultural production, climatic challenge,
population health, and ritual and mortuary activities - and although the
results of this work are essential to understanding the period, they are
also, by definition, impersonal. In attempting to untangle one young
boy’s encounter with disease and care in the context of the wider picture enabled by such broader research, this current study encourages a
focus on the relationships, motivations, concerns and practices of ordinary Nasca people in their daily lives.
The potential for a bioarchaeology of care analysis of the Nasca Boy
was greatly enhanced by the presence of soft tissue remains. While
skeletal evidence alone would have been sufficient to suggest a disabling lower body impairment and allow inference of care provision,
the availability of preserved organs permitted a conclusive diagnosis of
tuberculosis and a far more nuanced appreciation of the extent and
timing of disease process, including provision of an actual cause of
death. The preserved integument played an important role in interpretation by ‘fixing’ the subject in the position in which he was prepared for interment, leaving no doubt that his placement was intentional and held a specific meaning for those involved in his burial, even
if this meaning is now unclear.
As foreshadowed earlier, from a bioarchaeology of care viewpoint
there were some missed opportunities in the original analysis of the
Nasca Boy, possibly due to the fact that Allison et al. (1973) approached
their subject’s remains with one objective in mind and perceived information extraneous to this as irrelevant. The first of these missed
opportunities comprises the relative absence of reported archaeological
context; more data would have allowed an even richer bioarchaeology
of care analysis. Nonetheless, as has hopefully been demonstrated, it
was still possible to construct a credible account of past behaviour
based on what is available. The remaining ‘missed opportunities’ refer
to additional data that might have been available - but was not sought from the preserved soft tissue or related biological material available.
Allison et al. (1973:986) note that “[p]ieces of intestine and some
feces were removed” during the autopsy, but - in the second missed
opportunity - provide no further detail. Methodologies allowing analysis of preserved gut content and/or coprolites were employed from
the 1960s onwards to reconstruct diet (Bryant, 1974; Callen and
Cameron, 1960; Lin et al., 1978) and to document the presence of intestinal parasites (Samuels, 1965). The analysis of gut contents and/or
coprolites from the Nasca Boy may have provided information about
cultural dietary practices in response to disease (see Verostick et al.,
2018) and conceivably may also have provided evidence suggesting the
medicinal use of plant or other substances (see Zink et al., 2018;
Nystrom and Piombino-Mascali, 2017).
The third missed opportunity lies in the failure to analyse the Nasca
Boy’s hair - although this is not to be laid at the door of Allison et al.
(1973), who were working well before the development of appropriate
techniques. The hair follicle is one of the most metabolically active
tissues and yet is remarkably resistant to post-mortem diagenesis
(Wilson and Tobin, 2010). From the perspective of archaeological science, the preservation and recovery of hair provides rare access to
physiological and biochemical information about the individual, and
stable isotopic analyses of mummy hair for purposes such as reconstructing diet around the end of life and identifying the season in
which death occurred began in the 1990s (e.g. Aufderheide et al., 1994;
White, 1993; White and Schwarcz, 1994). During this period, researchers also started to analyse mummy hair for biochemical
4. Conclusion
The preserved tissue present in mummified remains may permit
identification of diseases and disease impacts which are invisible in
bone (Nystrom and Tilley, 2018), meaning that mummy studies are
potentially a particularly rich source of material for examining experience of disability and care in prehistory. The case of the Nasca Boy
case demonstrates the rewards of such analysis, and a quick survey of
the mummy studies literature reveals a raft of similarly promising
candidates for bioarchaeology of care research. One apposite illustration of this comes from Arriaza et al.’s (1995) study of tuberculosis in
Pre-Columbian northern Chile, which contains a meticulous description
of the physical characteristics and context of the mummified remains of
an 11–13 year old girl who died with advanced Pott’s disease; this girl
lived 300 years later than, and 250 kms south of, the Nasca Boy, but
both shared a similar physical environment and agro-pastoral lifeways,
and a superficial reading indicates comparability in the care each likely
received. From a different perspective, evidence from mummy remains
indicating pulmonary disease as the major cause of all-age morbidity
and mortality in Pre-Columbian coastal Chile (Aufderheide et al., 2002,
2008) suggests it would be interesting to attempt a modified bioarchaeology of care investigation of how a society responds to a significant
population-level health problem. There are many more examples we
could list, but instead we simply urge those in the field of mummy
studies to be aware of what may be achieved through bioarchaeology of
care analysis, and to consider applying this approach in their research either to new evidence or, as in this study of the Nasca Boy, to material
already in the public sphere.
Acknowledgements
We would like to thank Susana Arce, Director of El Museo Regional
de Ica ‘Adolfo Bermúdez Jenkins’, for talking to us (LT) about the ‘Nasca
Boy’ and for permission to take the photographs included in this article;
Sonia Guillen, for her magnificent work in organising the 9th World
Congress on Mummy Studies (Lima, 10–13 August 2016) at which the
case of the Nasca Boy was originally raised for consideration; and Jane
Buikstra, Editor in Chief of the IJPP, for her consistent support and
wisdom. We also thank the two anonymous reviewers, whose comments have helped us to clarify the context and aims of this paper for
readers unfamiliar with the bioarchaeology of care. In addition, Lorna
Tilley thanks her partner, Tony Cameron, for the material support
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International Journal of Paleopathology xxx (xxxx) xxx–xxx
L. Tilley, K. Nystrom
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Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.ijpp.2018.08.001.
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