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This paper reviews the significant advances in isotopic investigations in Andean South America and directs scholars to explore new theoretical and analytical directions, specifically the applicability of isotope data to paleopathology. Excellent preservation and large skeletal collections of human remains make the Central Andes ideal for biogeochemical reconstructions and advancements in isotopic methods. Our aims are twofold: first, we present a meta-analysis of stable and radiogenic isotope research in the Central Andes since 1985, and highlight those that combine analyses of isotope ratios and pathological conditions. Second, we discuss useful directions for incorporating stable isotope analysis more explicitly in studies of paleopathology in the Andes more in the future. Principle research foci have described dietary variation and regional population mobility since the 1980s, where early methodological explorations identified significant trends in isotopic variation. For the years 1980-2017, we identified 96 scholarly publications through a meta-data analysis of major peer-reviewed journals, book chapters, and conference proceedings. These demonstrate specific trends in topical and methodological preferences across the Andean region and a shift from 10 publications pre-1997 to 67 in the last 10 years. However, combined isotope and paleopathology studies in this region remain sparse; given the ecological, geological, and cultural complexity of the Central Andes, analyses of pathological conditions in different regions would significantly benefit from the information on diet, mobility, and local ecology that isotope ratios provide. Isotope analysis requires destruction of archaeological tissues, and interpreting isotope data can be complex, but it can also provide unique insights into the pathogenesis of multifactorial conditions and assist differential diagnosis. Therefore, we also discuss research designs for pairing isotopic and paleopathological variables that will allow researchers to better capture disease ecologies in archaeological samples and their variation across different regions, within related sites, and within individual lifespans.

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OBJECTIVE AND MATERIALS: This research evaluates the presence and chronology of tuberculosis (TB) in the northeastern highlands of Peru (CE 800-1535) through the analysis of osseous lesions from Pre-Contact Kuelap, Chachapoyas. METHODS: We examined macroscopic lesion morphology and distribution from the skeletal series (MNI = 207). RESULTS: We determined that skeletal evidence was highly consistent with advanced multifocal and spinal tuberculosis in 13 individuals. Destructive lesions of the lower thoracic and/or lumbar vertebra bodies and sacroiliac joints are evident in most cases, but we also observed lesions within the manubriosternal, hip, and knee joints. Both adult males (n = 7) and females (n = 6) present skeletal lesions from young adult to older adults, but there is only one late adolescent. Only three individuals demonstrate similar lesion distributions. CONCLUSIONS: Variation in lesion distribution in this population-based study shows the importance of identifying extra-vertebral tuberculosis and suggests that the disease may have manifested differently than at other coastal sites. These cases confirm the presence of tuberculosis both before and after Inca occupation across this central Andean highlands region. SIGNIFICANCE: This evidence for the likely endemic presence of TB in the New World prior to European Contact furthers our understanding of the distribution of this infectious disease across the region as well as elucidating lesion distribution. LIMITATIONS: The diagnosis of tuberculosis is based on skeletal lesions and it should be confirmed by molecular analysis. FUTURE RESEARCH: Additional examination of vertebral bodies (including juvenile remains) for evidence of earlier manifestations of infection.

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In the 20 years since the publication of John Verano's foundational paper "Advances in Paleopathology of Andean South America," paleopathological and bioarchaeological investigations of human skeletal remains in the region have increased dramatically. Today, primary foci have grown to span the identification of disease, detailed reconstructions of biocultural interactions, embodied social experiences, and ancient living worlds. In this special issue, more than a dozen scholars reflect on the state of developments in the scientific analyses of ancient disease, life, and society across the region. For this introductory article, we frame the current state of Andean paleopathology by reviewing key historical contributions beginning in the last century. More recent trends since 1997 are defined via a meta-analysis of the literature. We then highlight current innovations and consider future directions of study. We then close with an overview of the papers comprising this special issue. Each article explores major theoretical, topical, and methodological advances that have transpired since 1997 and charts the course for the next two decades of work - with implications and insights that transcend the Andes and speak to key paleopathological issues around the world.

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OBJECTIVES: Inca imperial strategies of political and territorial expansion varied across conquered regions depending on local ecology and cultural resistance, and Chachapoya peoples in Peru's forested northeastern Andes were renowned for their rebellions against the invaders. The cliff tombs of Los Pinchudos (AD 1470-1535) present opportunities to use stable isotopes to: (1) explore dietary and mobility patterns from a mortuary community interred at a site attributed to the poorly-known Chachapoya culture during the period of Inca domination, and (2) explore the origins of the individuals as either local or foreign (Inca). Using biochemical tracers, we can help resolve the impact of foreign influence and changes in population and social structure during imperial occupation. MATERIALS AND METHODS: While it is difficult to reconstruct individual life histories from incomplete skeletons, stable isotopic analysis of multiple skeletal tissues provides a direct means of characterizing diet and residential mobility. Values of stable carbon (δ13 C), nitrogen (δ15 N), and oxygen isotope (δ18 O) ratios were determined in bone and dentine collagen and bone and enamel carbonate from 28 samples (11 paired tissues) from males, females, and juveniles from Los Pinchudos. RESULTS: Dietary signatures are consistent with a mixed but more C3 -based plant and protein-based diet with moderate proportions of terrestrial animals. Oxygen isotopic values demonstrate limited variation between paired tissues, with a few possible nonlocal individuals buried in one particular tomb at the site. Compared to other Andean areas that underwent imperial domination, these data do not demonstrate expected dietary shifts. DISCUSSION: These are the first isotopic data from a Chachapoya site and our research shows evidence for minimal non-local presence in this commingled burial assemblage. The regional diet reconstructed at Los Pinchudos (2850 masl) focused on resources of higher altitude tuber crops, beans, and grains (C3 ) and terrestrial protein rather than on lower elevation grasses such as maize (C4 ) as in other highland Andean regions under Inca control. During imperial domination, inhabitants of this region appropriated Inca materials goods but continued to construct tombs in the local manner even though a potentially diverse population was occupying them.

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This paper analyses a diverse collection of previously undescribed cranial lesions observed from 42 individuals from the pre-Columbian site of Kuelap, eastern montane, Peru. I describe the presence of cranial lesions, their location on the vault location, shape, and size of affected area, and evidence of remodeling. Seventeen percent of the total cranial sample demonstrates similar superficial cranial lesions including males (25/117, 21.4%) and females (14/74, 18.9%), and adolescents (3/27, 11%). Most lesions are narrow ovals or long and leaf-shaped, with depression of the external cranial vault. While some are well-healed and smooth-surfaced, others are more irregular with variable degrees of remodeling. The highest frequency is on the superior and posterior aspects of the vault, usually along the sagittal plane. Differential diagnoses are considered but no single pathology is clear for all cases. There are some common features consistent with active and healing osteitis and a few are directly associated with trepanation. General patterning suggests intentional treatment, perhaps even possible cauterization of scalp injuries or healed infections. These large cranial "scars" have not been observed at coastal Peruvian sites and may reflect specific regional conditions related to highland environmental factors, local medical treatments of cranial injuries, or population specific malformations.

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This case study describes a unique anthropogenic modification of two individual skeletons excavated from the pre-Columbian site of Kuelap, Chachapoyas-Amazonas, in the northeastern highlands of Peru. While numerous examples of cranial trepanations using an adjacent drilling technique have been recovered from this site and region, this is the first example of such a surgical technique on a post-cranial element. Skeletal remains demonstrate that ancient Andeans were skilled and successful with many surgical treatments. Ethnohistoric documents suggest the Chachapoya shamans were known for their healing. In these cases, however, there is no evidence of long-term healing. This innovative medical procedure appears to have been an attempt at therapeutic intervention intended to treat an osteomyelitic infection of the distal tibial metaphysis.