Skeletal evidence for the emergence of i

It was found that skeletal evidence for infectious disease was absent in the Mid-Holocene, while over 10% of the Metal period sample exhibited lesions consistent with either infectious d

Skeletal Evidence for the Emergence of Infectious

Disease in Bronze and Iron Age Northern Vietnam

Marc F Oxenham,1* Nguyen Kim Thuy,2

and Nguyen Lan Cuong2

1School of Archaeology and Anthropology, Australian National University, Canberra, ACT 0200, Australia

2Institute of Archaeology, Ha Noi, Vietnam

KEY WORDS Vietnam; infectious disease; differential diagnosis; health

ABSTRACT Human skeletal evidence for the

emer-gence of chronic infectious disease in northern Vietnam is

examined The sample includes the remains of 192

indi-viduals representing the Mid-Holocene and Bronze to Iron

Ages The objective is to see if the transition from

seden-tary, foraging, coastally oriented economies to centralized

chiefdoms with attendant development and intensification

of agriculture, trade, metal technologies, warfare, and

population increase was accompanied by an emergence of

and/or increase in infectious disease It was found that

skeletal evidence for infectious disease was absent in the

Mid-Holocene, while over 10% of the Metal period sample

exhibited lesions consistent with either infectious disease

or immune system disorders Factors potentially

contrib-uting to the emergence of infectious disease in northern Vietnam in the Metal period include: increased contact with bacterial or fungal pathogens either directly or by way of vertebrate and/or arthropod vectors; higher levels

of debilitation and/or decreased levels of immunocompe-tence in the Metal period; and evolution of pathogens present in Mid-Holocene human hosts into more virulent forms in the Metal period The first two factors may be related to historically and archaeologically documented major demographic (Han colonizing efforts) and economic (agricultural intensification) changes in the region during the Metal period Am J Phys Anthropol 126:359 –376,

2005 © 2004 Wiley-Liss, Inc.

This study is concerned with identifying,

quanti-fying, and discussing the implications of skeletal

evidence for infectious disease among the

inhabit-ants of the northern portion of the Socialist Republic

of Vietnam, during the Mid-Holocene and Metal

pe-riods It is based on skeletal remains of 192

individ-uals excavated from archaeological sites in the

re-gion from the 1960s through the 1990s For the most

part, previous studies of human skeletal material

recovered from Vietnam focused on Late Pleistocene

and Holocene morphology, patterns of

microevolu-tionary change, and population movement within

East Asia (Demeter, 1999; Demeter et al., 2000;

Matsumura et al., 2001; Nguyen KT, 1990, 1998;

Nguyen LC, 1985, 1992, 1996; Olivier, 1966;

Pi-etrusewsky, 1988; Pietrusewsky et al., 1992)

Oral health (Oxenham and Nguyen, 2002;

Oxen-ham et al., 2002) and the evidence and implications

of traumatic injury (Oxenham et al., 2001) in

pre-historic northern Vietnamese samples were

previ-ously examined However, very little is known

re-garding the presence, let alone origins and

distribution, of skeletally sensitive infectious

dis-ease in prehistoric Vietnam For Southeast Asia as a

whole, a small and growing body of literature is

detailing the presence and distribution of disease in

this bioarchaeologically undersampled region of the

globe Tayles (1996, 1999) examined the evidence for

chronic infectious disease in the form of malaria,

and associated biological adaptations to this disease

in the form of genetically transmitted hemoglobi-nopathies, in prehistoric Thailand Indriati (per-sonal communication) analyzed skeletal lesions con-sistent with tuberculosis in the remains of an individual recovered from a bronze drum inhuma-tion, dated to approximately 2,300 years ago, in central Java, Indonesia Pietrusewsky and Douglas (2002) outlined a range of infections at the 4,100 – 1,800-year-old site Ban Chiang, northern Thailand, including mastoiditis, pulmonary disease, and non-specific infections identified by way of localized peri-ostitis Tuberculosis may have been present in Thai-land in the 5,500 –3,000-year-old assemblage from Non Nok Tha (Pietrusewsky, 1974; Douglas, 1996) and perhaps in the 2,200 –1,700-year-old sample from Noen U-Loke (Tayles and Buckley, in press) Intriguingly, a good argument for the appearance of leprosy at Noen U-Loke has also been developed (Tayles and Buckley, in press)

*Correspondence to: Marc Oxenham, School of Archaeology and Anthropology, Australian National University, Canberra, ACT 0200, Australia E-mail: marc.oxenham@anu.edu.au

Received 6 May 2002; accepted 3 February 2004.

DOI 10.1002/ajpa.20048 Published online 8 September 2004 in Wiley InterScience (www interscience.wiley.com).

BIOCULTURAL CONTEXT

A review of contemporary Vietnam’s climate and

geography provides a useful, and for the most part

representative, insight into Mid-to-Late Holocene

conditions The following summary is drawn from

Nguyen TD (1995) Topographically, while about

three-quarters of Vietnam can be described as

mountainous, 85% of the mountains are below 1,000

m in elevation Vietnam has three plains systems

that are still in the process of expansion The

ar-chaeological sites of interest here are situated in the

northern Bac Bo plain and fall between latitude

18 –22° north This northern plain is low-lying,

av-eraging between 0.3–10 m above sea level

Vietnam presents two distinct climatic zones, a

northern and a southern Northern Vietnam has two

seasons, cold and hot, but with high levels of

humid-ity occurring during both periods The north

experi-ences marked climatic variability or instability that

has restricted levels of ecological variation in

com-parison to the south The area is prone to typhoons,

violent storms, and torrential downpours which

have caused extensive agricultural and human

dis-ruption in the present and the past Coastally,

man-groves still predominate, while dense bamboo

for-ests are common all over the northern plains

Northern Vietnam is home to a diverse range of bird,

riverine, and marine life Some 900 species of fish

are recognized in the Gulf of Bac Bo alone

Terres-trial animals such as sambar deer, muntjac,

cham-ois, and numerous arboreal primates are still

com-mon in the region In the past, elephant, rhinoceros,

tiger, and panther were also common

The earliest accepted period of anatomically

mod-ern human occupation in northmod-ern Vietnam, the Son

Vi Culture, dates back approximately 30,000 ybp

(Nguyen KS, 1996) While the Son Vi continues until

some 11,000 ybp, a new culture period,

character-ized for the most part by lithic artifact morphology,

emerged around 18,000 ybp, and is termed the Hoa

Binh or Hoabinhian Communities attributable to

the Hoabinhian period, which lasts until

approxi-mately 6,000 ybp, were involved in hunting and

gathering a wide variety of mammals, birds, fish,

and shellfish (Higham, 1989), and may have

prac-ticed an incipient form of horticulture (Gorman,

1971) The relationship between post-Hoabinhian

communities, which are principally coastally

ori-ented, and the Hoabinhian itself is unclear, as the

latter is virtually always restricted to inland caves

and rock shelters

The earliest skeletal material to be examined in

this study is sampled from the initial phase of the

Da But culture This archaeological culture, lasting

for approximately 1,700 years, is considered one of a

number of emergent Mid-Holocene cultures with a

coastal/marine economic focus that developed out of

the Hoabinhian approximately 6,500 ybp (Bui Vinh,

1991, 1994, 1996; Nguyen KS, 1997)

Morphologi-cally, these people have been characterized as

“Aus-tralo-Melanesians,” in distinction to the Metal pe-riod people who are considered “Mongoloid” or Northeast Asian in appearance (Matsumura et al., 2001)

Da But sites are for the most part shell middens that include polished stone artifacts, pottery, and arguably domesticated pigs and buffalo as well as human burials (Bui Vinh, 1991) The people are characterized as sedentary foragers with a marked marine/aquatic resource dependency (Yasutomo, unpublished findings) The first appearance of fish-ing net sinkers, spinnfish-ing whorls, stone awls, stone chisels, and technological changes in stone axes oc-cur during the Middle Da But, about 5,500 ybp Moreover, there is a large increase in the frequency

of polished and curved stone artifacts that have been interpreted as hoes (Bui Vinh, 1991) There is also

an increase in the number of domesticated buffalo and pig remains (Bui Vinh, 1996) The final phase of the Da But period, beginning around 5,000 ybp, is characterized by technological changes with respect

to pottery and stone artifacts Settlements spread along the coast, and the development of sea travel and sea fishing is suggested (Bui Vinh, 1991, 1996) The next general culture period for which a large sample of skeletal material is available occurs dur-ing the development of metal technologies The ear-liest evidence for metal in northern Vietnam ap-pears in late Phung Nguyen culture contexts, although no skeletal material has been recovered from this period These sites are situated on rela-tively raised areas to the northern edge of the Red River delta The Phung Nguyen culture, believed to have lasted from 4,000 –3,500 ybp, is notable for its rich and technologically sophisticated array of stone jewelry Following this period, the Dong Dau phase, 3,500 –3,000 ybp, ushers in a major development in bronze-working technology with the appearance of spears and arrowheads, as well as more utilitarian items such as fishing hooks, chisels, and axes The Dong Dau phase is followed by the Go Mun period, 3,000 –2,500 ybp, and is characterized by the devel-opment of an enormous range of decorative, utilitar-ian, ritual, and martial items (Higham, 1996) Emerging from these early bronze phases is the Dong Son culture, flourishing in northern Vietnam from 2,500 ybp until Han domination and colonizing efforts in the first centuries of the first millennium CE

Higham (1989, p 30) described the Vietnamese Dong Son as one of several Southeast Asian exam-ples demonstrating social differentiation and a move

“from village autonomy towards centralised chief-doms.” Apart from the diverse range and technolog-ical sophistication of material culture objects, e.g., richly decorated bronze drums exceeding 80 kg, there is evidence of marked craft specialization, a complex ritual life, the development of an aristo-cratic and centralized elite, maritime trade, and so-phisticated military skills and equipment One no-table example of the material achievements of this

period can be seen in the surviving earthen

struc-tures of the 600 ha former capital Co Loa, built on

the Red River plains some 2,200 ybp

The preceding discussion invites the development

of a hypothesis that proposes that the populations

sampled from both periods will have suffered from

infectious disease, but at a higher frequency in the

Metal period sample While the population density

of Da But period Vietnam is unclear, many midden

sites have been identified, and the evidence for

re-duced mobility is strong for sites such as Con Co

Ngua at least An increased degree of residential

sedentism and increased population density are also

indicated for the Metal period In addition, the

sub-tropical environment and apparent early

domestica-tion of large vertebrates suggest the potential for the

early emergence of infectious disease either via the

environment directly or by way of zoonoses

Histor-ical evidence for Han military campaigns and

colo-nization of the region, in addition to intensification

of land modification and agriculture in the Dong

Song period particularly, increases the probability of

the development of infectious diseases at this time

In testing this hypothesis, we will examine the

evi-dence for infectious disease in Mid-Holocene and

early Metal period Vietnam, and attempt to identify

the types of disease that are present in order to

better understand the actual health implications

Any observed differences in the frequency and

na-ture of infectious disease over time will be discussed

within the respective biocultural context of each

sample and with respect to current theoretical

mod-els of infectious disease

MATERIALS AND METHODS

Table 1 summarizes the sample sizes, dates, and

localities of human remains examined in this study,

and Figure 1 shows the location of each site with

skeletal remains The Da But period sample is

com-posed of 96 individuals excavated from the

Mid-Holocene site Con Co Ngua in Thanh Hoa Province,

northern Vietnam, in 1979 and is dated to between

6,000 –5,500 ybp (Bui Vinh, 1980) The Metal period sample is an aggregation of 96 individuals from 11 separate archaeological sites in northern Vietnam that spans 3,300 –1,700 ybp The majority of this sample derives from the Dong Son stage, with the remaining individuals belonging to either the Dong Dau or Go Mun phases

The level of infracranial preservation in the Da But sample is much better than for the Metal period (Table 2), while both samples display similar levels

of cranial and dental preservation The most poorly preserved portions of both samples include the ver-tebrae, os coxae, and fibulae After the cranium, more robust bones such as the humerus and femur are the best-preserved elements in each assemblage Tropical soils are generally acidic and not conducive

to bone preservation Metal period burial practices involved extended burial in soil, whereas at Con Co Ngua, individuals were buried in a squatting

pos-TABLE 1 Study sample summary

Period Sample Abbreviation Region Individuals Date (ybp) 1

1 Refers to date of skeletal sample.

2 Radiocarbon date.

Fig 1. Map of northern Vietnam, showing location of sites with skeletal remains examined in this study (from Oxenham et al., 2002).

INFECTIOUS DISEASE IN BRONZE AGE VIETNAM 361

ture within shell midden material The

remineral-ization afforded by this latter practice no doubt

con-tributed to better preservation at Con Co Ngua

The age-at-death profiles for each assemblage

(Ta-ble 3) indicate poor infant and subadult

representa-tion The Con Co Ngua sample is skewed toward

older ages, with 69% of the sample 30 years of age or

older, compared to 48% of the Metal period sample

There are also apparent sex imbalances within each

assemblage, with a higher ratio of males at Con Co

Ngua (1.4:1), and a higher ratio of females in the

Metal period sample (1.3:1) Approximately 13% of

each sample could not be reliably sexed, and this

may account for these differences in assemblage

composition

Every preserved element of every individual was

examined macroscopically for evidence of

patholog-ical lesions Where lesions were suspected they were

described in detail, photographed, and X-rayed In

cases where a systemic condition was suspected, the

entire preserved skeleton was X-rayed If observed

pathological conditions were characteristic enough

to potentially enable identification of the disease

process responsible a differential diagnosis was

car-ried out Due to the wealth of descriptive material

and sometimes extensive differential diagnoses, these results can only be summarized here

RESULTS General health

Evidence for general health and well-being in each sample is reviewed here, based on recent work by Oxenham (in press; see also Oxenham et al., 2001; Oxenham and Nguyen, 2002; Oxenham, 2000) These results provide a generalized health context

in which to evaluate the evidence and implications for more specific forms of disease in these samples The oral health of the dental sample from Con Co Ngua is good, with low tooth count rates of carious lesions (14/951, 1.5%), abscesses (22/1,430, 1.5%), and antemortem tooth loss (69/1,430, 4.8%) The evidence from cribra orbitalia and enamel hypopla-sia suggests somewhat compromised physiological well-being at Con Co Ngua Of all individuals with assessable orbits, 81% (47/58) had lesions on a con-tinuum of active to highly remodeled No statistical significance for the frequency of cribra orbitalia by age-at-death was found The frequency of canine linear enamel hypoplasia by individual (left canine

TABLE 2 Major skeletal element preservation

Element

Vietnam Da But period Vietnam Metal period Expected n Obs 1 % Obs Complete Obs 2 % complete Expected n Obs 1 % Obs Complete Obs 2 % complete

1 Includes any state of preservation.

2 Includes elements greater than 50% preserved.

Obs, observed; na, not applicable.

TABLE 3 Sample sex and age-at-death profiles

Age class

Vietnam Da But sample Vietnam Metal period sample

1 Adult but could not be assigned to an age category.

2 Too fragmentary to assign as adult or subadult.

na, not applicable.

TABLE 4 Frequency of nontraumatic lesions

Lesion type

Elements 1 Individuals 2

Dong Son Vertebral articular process Lytic 107 2 1.9 18 2 11.1

1 More than 50% complete.

2 Represented by a given element more than 50% complete.

Obs, observed.

TABLE 5 Summary of lesion descriptions and differential diagnoses1 Period Individual 2 Sex Age inyears Bone Lesion type/position Lesion size(mm) Lesionshape Remodelling Differential diagnosis

Da But 80CCN M 50 ⫹ Right humerus Lytic (distal epiphysis) 16.8 Circular S Chondroblastoma

Giant-cell tumor Pigmented villonodular-synovitis

Dong Son 70DC SA 5 ⫾ 1.5 Left parietal Lytic (postero-superior) 7.4 ⫻ 5.7 Oval S, V Langerhan’s cell

histiocytosis

Mycotic infection Neolplastic Dong Son 89MD F 40–49 Right os coxae Lytic (superior ischial

tuberosity)

4.0 Circular V Nonspecific infection M2a

Dong Son 89MD F 20–29 Right frontal Lytic (adjacent to

bregma)

7.5 Circular S, V Langerhan’s cell

histiocytosis

Neoplastic Mycotic infection Right frontal Blastic (osteoma on

frontal boss)

4.2 Circular S Trauma, inflamatory

process, neoplasm, genetic

Dong Son 89MD F 40–49 Left humerus Blastic (periostitis of

proximal and mid diaphysis)

12.5 ⫻ 5.2 Irregular V, P Nonspecific localized

infection

Dong Son 76NN M 40–49 Left temporal Lytic (suprameatal

triangle)

9.0 Circular S, V, P Langerhan’s cell

histiocytosis

Aneurysmal cyst Neoplastic Epidermoid cyst Dong Son 77NN M 20–29 Left temporal Lytic (mastoid;

multiple)

2.0–6.0 Circular Mastoiditis

cholesteatoma Sarcoidosis Mycotic infection Dong Son 78NN F 30–39 Right

temporal

Lytic (mastoid;

multiple)

Circular See 77NN M10ka

Dong Son 95DX F 30–39 Thoracic 3 Lytic (articular process) na Mycotic infection

M1a Thoracic 4 Lytic (articular process) na Tuberculosis

Thoracic 9 Lytic (body) 12.0 Circular Osteomyelitis Thoracic 10 Lytic (body) 16.7 Circular Neoplastic Left os coxae Lytic (ischium) 19.0 ⫻ 11.5 Oval

Dong Son 84DS F Adult Left frontal Blastic (osteoma on

frontal boss)

20.0 Circular S See 89MD M7a M9a

Dong Son 77CHS M 50 ⫹ Left femur Blastic (periostitis of

distal metaphysis)

Diffuse Irregular V, P Nonspecific localized

infection M1a

Right ulna Blastic (periostitis of

midshaft)

7.5 ⫻ 30.0 Irregular V, P

1 Sex: SA, unsexed subadult; M, male; F, female Remodelling: S, sclerosis observed either macroscopically or radiologically; V, vascular porosity; P, periostitis.

2 Number prefixing individual code is excavation year (e.g., 70DC ⫽ Duong Co, 1970 excavation); letter/numeral combination on next line represents burial designation (e.g., M1a ⫽ burial number 1a).

INFECTIOUS DISEASE IN BRONZE AGE VIETNAM 363

or antimere substitution) is 71.7% (38/53), with a

mean number of linear events per tooth of 2.4

Again, the frequency of linear enamel hypoplasia by

age-at-death was not found to be significant Risks

from serious injury are elevated in comparison with

other Southeast Asian assemblages For instance,

healed fractures (by element) of the femoral

diaph-ysis are 6.5%, and of the humerus, 4.4%

The oral health of an aggregated Metal period

sample is reasonably good, with no statistically

sig-nificant differences in comparison to the oral health

of the Da But sample in terms of carious lesions by tooth count (26/1,152, 2.3%), abscesses (39/1,518, 2.6%), or antemortem tooth loss (46/1,518, 3.0%) As was the case for the Da But assemblage, the fre-quencies of cribra orbitalia and enamel hypoplasia suggest compromised physiological health, although there are no significant differences in the frequency

of these health markers between temporal periods

Of those individuals with assessable orbits, 73.2% (41/56) had active or remodeled lesions No statisti-cal significance for the frequency of cribra orbitalia

TABLE 6 Skeletal inventory of individuals with lesions

80CCNM74a

Cranial Calva; maxillary arcade from left M1–I1, right arcade from C–M1; mandibular body from P3–M3 and right

body from P3–M1 Clavicle Left complete; right diaphysis

Scapula Fragment of superior glenoid and coracoid; complete right glenoid and acromion

Rib 4 left and 1 right articular fragments, and 18 other small fragments

Humerus Left complete; right condyles and fragment of proximal head

Radius Proximal 1/3 left diaphysis; right nearly complete (missing distal metaphysis)

Ulna Left proximal 3/4; right head

Hand Left M3 proximal 2/3; right M1 and M3 proximal 2/3; 4 proximal row phalanges

Vertebra Dens and left facets of atlas, 2 thoracic centra, L5 centrum

Sacrum Promontory

Femur Left distal 3/4; right condyles and proximal 1/3 of diaphysis

Patella Left and right complete

Tibia Left head and distal 1/3; right almost complete

Fibula Distal articular section of right and section of mid diaphysis

Os coxae Fragment of posterior right ilium and complete auricular area

70DCM1a

Cranial Left side of calva, but includes right orbit and large section of right occipital; maxilla from

permanent M1–M1 Fragment of left mandibular body, including unerupted M1 and dm2 alveolus 89MDM2a

Cranial Complete cranium, maxilla, and mandible

Sternum Complete body

Clavicle Complete left

Scapula Left and right complete

Rib 8 complete left and 8 complete right

Humerus Complete left

Radius Complete right

Ulna Complete left

Vertebra Complete atlas, T1, T2, T11, T12, L4; complete sacrum (missing coccyx)

Os coxae Left and right complete except for pubic symphyses

Femur Complete right

Tibia Left distal 4/5

Fibula Left diaphysis proximal 3/4

Foot Complete left calcaneus

89MDM7a

Cranial Complete cranium; complete maxilla; complete mandible

Humerus Near complete right

Radius Complete right

Sacrum Complete

Femur Left proximal 3/4

Tibia Left diaphysis proximal 3/4

Fibula Left distal 3/4; right complete

89MDM8a

Cranial Complete cranium, maxilla, and mandible

Clavicle Left and right complete

Scapula Left and right complete

Sternum Manubrium and sternal body

Humerus Left and right complete

Radius Left and right complete

Ulna Left and right complete

Vertebra Axis, C3–C7, T2–T11, L1–L5 complete

Femur Left and right complete

Patella Left and right complete

Tibia Left and right complete

Fibula Left and right complete

Foot Right talus complete; left and right calcanea complete; left navicular and cuboid; right navicular and cuboid,

1st cuneiform; left and right M2–M5

(continued)

by age-at-death was found The frequency of canine

linear enamel hypoplasia by individual is 67.3% (37/

55), with a mean number of linear events per tooth

of 2.9 Again, the frequency of linear enamel

hyp-oplasia by age-at-death was not found to be

statis-tically significant Risks from serious injury are very

low in comparison with the Da But period and other

Southeast Asian assemblages Only one proximal

radial fracture (1/14, 7.1%) and one distal ulna

frac-ture (1/14, 7.1%) were noted The apparent high

frequencies are due to poor infracranial

preserva-tion of the Metal period sample

Frequency of nontraumatic lesions

Table 4 summarizes the frequency of observed

lesions by element and individual for each

assem-blage Despite reasonably good preservation of nial elements at Con Co Ngua, no evidence for cra-nial lesions was observed Only one nontraumatic lesion was observed in the entire Con Co Ngua in-fracranial sample with 1.4% of humerii affected, or 2.3% of individuals In the Metal period assemblage, 10.9% (6/55) of those individuals with 50% or more preservation of cranial elements displayed patholog-ical lesions The majority of lesions are lytic, with the temporal bone being the most frequently af-fected cranial element Only two individuals dis-played cranial blastic lesions in the form of button osteomas on the frontal bone The most frequently affected infracranial element is the os coxae, with lytic lesions to the ischial portion in 11.1% of ob-served elements or 16.7% of individuals One Metal

TABLE 6 (continued)

76NNM2c

Cranial Calva including face; most of maxilla; complete mandible

Clavicle Left medial 1/2; right medial 3/4

Humerus Left and right distal 3/4

Radius Left distal 3/4; right proximal 1/4 and mid-diaphysis 1/3

Ulna Left proximal and distal 1/3 of diaphysis; right complete

Hand Right navicular and capitate, M2 proximal 1/2, M3 distal third; 3 proximal row phalanges, 2 midrow phalanges Vertebra Left articular facets of atlas, left 1/2 of axis, C5–6 centra

Femur Left and right proximal 2/3 diaphysis

Patella Left complete

Os coxae Left auricular area including greater sciatic notch, fragment of superior acetabulum; right superior acetabular

fragment 77NNM10ka

Cranial Much of cranium but missing base; complete mandible

Most of maxilla, but right arcade missing posterior to M1

78NNM7ka

Cranial Much of cranium but missing base; complete alveolar process of maxilla; most of mandible, but missing left

ascending ramus and condyle 95DXM1a

Cranial Complete cranium, maxilla, and mandible

Clavicle Left diaphysis and acromial end; right complete

Sternum Manubrium and sternal body

Scapula Left and right coracoid/acromion/glenoid fossa complexes

Rib 23 articular processes preserved, with most including medial 1/3 of shaft; 13 fragments, including central and

distal region of the rib Humerus Complete left and right

Radius Left proximal 2/3; right complete

Ulna Left proximal 3/4; right complete

Hand Left navicular, lunate, capitate, hamate, M1–M5; right lesser and greater multangulars, lunate, hamate, M1–M5;

8 proximal row phalanges, 1 midphalanx, 3 distal row phalanges

Os coxae Left and right complete, except missing pubic symphyses

Vertebra Complete C1–L5

Sacrum Much of the left lateral portion missing

Femur Left and right complete

Tibia Left and right complete

Fibula Left and right complete

Foot Left and right calcanea and tali complete; left 1st, 2nd, and 3rd cuneiforms, navicular, M1 (distal two-thirds),

first proximal and distal phalanges; right first, second, and third cuneiforms, cuboid, navicular, M1 (proximal 1/4), M2–M3, first distal phalanx

84DSM9a

Cranial Calva; mandibular fragment left M3–P3

Foot Left and right tali complete

77CHSM1a

Cranial Complete cranium, maxilla, and mandible

Scapula Right coracoid/acromion/glenoid fossa complex

Humerus Left complete

Radius Left complete

Ulna Left and right complete

Vertebra Axis, C7–L5 complete

Rib 3 complete right

Femur Left distal 3/4

Patella Left complete

Tibia Left complete

Foot Left 1st cuneiform

INFECTIOUS DISEASE IN BRONZE AGE VIETNAM 365

period individual displayed destructive lesions of

the vertebral articular processes and bodies Blastic

lesions of the infracranial skeleton presented as

lo-calized areas of slight periostitis in the following

frequencies: humerus, 3.4% of elements and 5.0%

individuals; femur, 3.6% of elements and 5.9%

indi-viduals; and ulna, 4.8% elements and 7.1%

individ-uals While it is difficult to estimate the actual

over-all frequency of lesions for each sample due to the

differential preservation of individual skeletons,

minimally 10.4% (10/96) of Metal period and 1.0%

(1/96) of Da But period individuals displayed

non-traumatic pathological lesions Further, while 20%

of the Metal period sample covers the earlier Dong

Dau and Go Mun periods, only Dong Son period

individuals displayed pathological lesions

Lesion descriptions

Table 5 summarizes the evidence for lesions and

the possible disease processes responsible, while

Ta-ble 6 describes the preservation of each individual

displaying a lesion For those cases where the

mor-phology and location or distribution of the lesion(s)

invited diagnosis of the underlying disease process

responsible, the lesions and individuals are

exam-ined here in more detail The first case to be

de-scribed is the only individual with a nontraumatic

lesion from the Da But period sample, a male aged

over 50 years His right humerus has a large

spher-ical lesion on the posterior aspect of the lateral

epi-condyle that has resorbed the posterior face of the

condyle and encroached onto the postero-lateral

bor-der of the capitulum (Fig 2) The perimeter of the

lesion is slightly sclerotic, and the interior walls are

smooth with some porosity and discolored with an

unidentified black substance There is no sign of

vascularity surrounding the lesion, which is 16.8

mm in diameter and 8.0 mm at its deepest A

radio-graphic examination of all the skeletal material

at-tributed to this individual failed to reveal any

fur-ther lesions

The following cases all belong to the Dong Son

phase of the Metal period A young child from Duong

Co (70DCM1a), represented by cranial remains only,

has a lytic lesion on the rear left parietal bone The

slightly sclerotic perimeter of this oval lesion is

reg-ular and well-demarcated, and it penetrates the

outer table and diploe with an average depth of 3.0

mm The floor of the lesion is slightly remodeled or

sclerotic A pale but distinct ring of discolored bone

encircles the lesion, which is wider inferiorly than

superiorly The pale ring of bone is dotted, with

numerous tiny pits indicating some degree of

vascu-larity in life (Fig 3) With the exception of the cribra

orbitalia, no other pathologies were present, and

this was confirmed on X-ray The deciduous

maxil-lary molars, the only preserved primary dentition,

were present and did not display any enamel

de-fects

A young adult from Minh Duc (89MDM7a) has a

circular lytic lesion restricted to the outer table and

diploe, with somewhat roughened slightly sclerotic edges and floor, situated just anterior to the coronal suture and just lateral to bregma, high on the right side of the frontal bone (Fig 4) A ring of concen-trated pitting completely surrounds the edges of the lesion and averages 2.5 mm in width There is an-other band of slightly darker, smoan-other, and shinier bone also surrounding the lesion, which ranges from

a minimum width of 5.5 mm to a maximum width of 12.0 mm There is also a small (4.2 mm in diameter) button osteoma on the right frontal tuber There is extensive cribra orbitalia and associated remodeling

in both orbits No evidence of oral pathology or enamel defects was observed

The Ma River site male 76NNM2c has a large lytic lesion just superior to the external auditory meatus

on the left temporal bone (Fig 5) The structures of the external auditory meatus are nearly completely lost postmortem: all that remains is the superior border of the meatus, including most of the temporo-mandibular joint (TMJ) fossa The lesion is situated directly over the usual position of the suprameatal triangle and is almost perfectly circular, is 9.0 mm

in diameter, and intrudes approximately 9.0 mm at its deepest point The floor and the sides of the lesion are roughened, and it is surrounded by scattered porosity with a localized area of periostitis on the posterior border There is no indication macroscopi-cally or radiologimacroscopi-cally that the lesion communicated with the mastoid antrum Additionally, this individ-ual displayed an extensively remodeled cribra or-bitalia Endocranially, there is extensive pacchion-ian, or arachnoid, pitting running from midfrontal to vertex all along the sagittal plane Very deep men-ingeal grooves run parallel to the coronal suture with the right one, 15.0 mm in diameter, ending in a large pacchionian lacuna near bregma Numerous pits are present within the left meningeal groove and tributaries The teeth are severely worn, with eight teeth displaying attrition-induced pulp cham-ber exposure Due to this level of wear, there were numerous alveolar defects of pulpal origin (granulo-mas/abscesses)

A 20 –29-year-old male, 77NNM10ka, from the Metal period site of Nui Nap, presents with exten-sive destruction of the mastoid process of the left temporal bone Much of the outer table of the mas-toid is completely eroded, leaving visible the net-work of small honeycomb-like sinuses There are several more isolated holes in the superior region of the process just inferior to the most posterior exten-sion of the zygomatic crest, the supramastoid crest There are at least three confluent lesions in this region, ranging in size from 4.5–5.8mm in diameter, with regular smooth sloping edges (Fig 6) There is

no sign of pitting or vascularity associated with any

of the lesions The latero-posterior aspect of the con-dyle of the mandible has been eroded There is also the remnant of a circular lesion on the dorso-lateral edge of the condyle The lesion is 2.2 mm in diame-ter, with smooth edges and walls This may be

lated to the extensive lytic destruction of the left

mastoid Both orbits displayed clear evidence of

highly remodeled cribra orbitalia Endocranially,

there were pacchionian pits on the left parietal

ad-jacent to the sagittal suture In fact, there is a large

(40.0 mm diameter) depression just distal to bregma

and bisected by the sagittal suture This is probably

a large, shallow pacchionian lacuna This lacuna

contains several clusters of smaller pacchionian pits Such extensive granulation activity is unusual

in such a young individual (Mann and Murphy, 1990) This individual was free from alveolar defects

of pulpal origin and caries, but the maxillary ca-nines and incisors displayed enamel hypoplasia The

Fig 2. 80CCNM74a A 50 ⫹ year-old male Large lytic lesion

on distal epiphysis of right humerus (anterior view).

Fig 3. 70DCM1a Aged 5 years ⫾ 16 months Lytic lesion on

posterior aspect of left parietal bone (lambdoid suture at bottom

right; dorsal at top of photo).

Fig 4. 89MDM7a A 20 –29-year-old female Lytic lesion pen-etrating outer table and diploe of frontal bone, just forward and to left of bregma (anterior of cranium at right in photo).

Fig 5. 76NNM2c A 40 – 49-year-old male Lytic lesion, with associated slight periostitis, situated over suprameatal triangle of left temporal bone (anterior of cranium at left in photo) INFECTIOUS DISEASE IN BRONZE AGE VIETNAM 367

anterior teeth exhibited a deep red betel nut (Areca

catechu) stain (Oxenham et al., 2002b).

The final individual to be detailed here is the

30 –39-year-old female, 95DXM1a, from the Metal

period site Dong Xa The right inferior interarticular

facet of the third thoracic vertebra (T3) has been

completely destroyed There is extensive porosity

surrounding the lesion, or the former site of the

articular facet (Fig 7) The corresponding right

su-perior facet of T4 is completely eroded away, with

only porous, slightly remodeled trabecular bone

re-maining There is extensive erosion of the dorsal and dorso-anterior centrum and the tips of all processes and antemortem erosion of the left superior interar-ticular facet, which corresponds to slight erosion of the T3 left inferior facet T8 displays erosion of the dorsal, left lateral, and much of the ventral aspect of the centrum A large scooped-out lesion presents in the left lateral aspect of the T9 centrum, which is approximately 12.0 mm in diameter, with a maxi-mum depth of 10.0 mm (Fig 8) The lesion is circular and internally spherical, with the walls and floor being exposed porous trabecular bone There is also considerable erosion of the anterior and antero-ven-tral aspects of the centrum The left latero-posterior aspect of the T10 centrum presents a large scalloped lesion which extends as far posteriorly as the base of the left lateral transverse process (Fig 8) It is roughly spherical, internally exposing porous tra-becular bone, and measures 16.7 mm in diameter by 12.2 mm deep Additional features include erosion of the upper anterior aspect of the centrum and an oval hollow in the antero-dorsal right lateral portion of the centrum

The left os coxae has a shallow oval lesion on the medial face of the superior ischial ramus measuring

Fig 6. 77NNM10ka A 20 –29-year-old male Note

well-cir-cumscribed lesions in superior portion of left mastoid and

mas-sive destruction of lower aspect of mastoid (anterior of cranium at

left in photo).

Fig 7. 95DXM1a A 30 –39-year-old female Note complete

destruction of right, inferior interarticular facet of the third

cer-vical vertebra (inferior view).

Fig 8. 95DXM1a Note destruction of cortex of T8 (left of photo) and large space-occupying lesions on lateral aspects of T9 and T10 (left lateral view of lower thoracic vertebrae).