Disease and Mortality in the Early Bronze Age People of Bab edh-Dhra, Jordan DONALD J. ORTNER Department of Anthropolog?, National Museum of Natural History, Smithsonian Institution, Washington, D C. 20560 K E Y WORDS Paleopathology . Mortality . Early Bronze Age Jordan ABSTRACT During the 1977 field season a t the Early Bronze Age site of Bab edh-Dhra 92 individuals were recovered from underground shaft tomb chambers. Morbid conditions found in these skeletons include trauma, possibly two cases of tuberculosis, osteomyelitis, post-menopausal osteoporosis and congenital anomalies. Of the 92 skeletons recovered 56 (61%)were 18 years of age or older, 28 (30%)were between 1 and 18 years of age and 8 (9%)were less than one year of age. Disease, particularly of the infectious variety, is one of the most important factors affecting human populations. In man's more recent past plague and epidemic decimated major cities and were important factors in the demise of some human populations !McNeillt '77). The role of disease in human adaptation is, thus, one of the important problems in the study of human biological history. As with most problems in physical anthropology, sources of data are less than desirable. Of these sources skeletal remains are the most ubiquitous but morbid conditions which affect the skeleton are relatively rare. For example skeletal responses to infectious disease are largely limited to chronic conditions. Acute conditions, such as those typically associated with epidemic, rarely affect the skeleton and skeletal manifestations in those that do may be non-specific. Despite these limitations there is much that can be learned about the history of disease and the effect of disease on a human population through the study of skeletal remains. I should like t o review the evidence for several morbid conditions found in the skeletal remains from the Early Bronze Age cemetery of Bab edh-Dhra in Jordan. The skeletons in this report were obtained during excavations in the cemetery in May and June of 1977. Bab edh-Dhra is located near the shores of the Dead Sea about one kilometer east of El Mazra, a modern town located adjacent to AM. J. PHYS. ANTHROP. (1979) 51: 589-598. the northern portion of the Lisan peninsula which juts out into the Dead Sea from Jordanian shore. The most prominent feature of the site of Bab edh-Dhra is the ruin of the large fortified town. The outer stone wall encompassed an area of approximately nine acres and provided housing for a minimum of 600 people. The cemetery is located south of the town ruin. The boundaries of the cemetery have not yet been carefully defined but clearly they encompass several square kilometers and c o n t a i n t h o u s a n d s of h u m a n s k e l e t o n s (Lapp, '68). Burials in the cemetery are in underground tombs or ground level charnel houses. Differences in burial practice reflect cultural changes taking place during the occupation of the site. This occupation lasted from about 3150 to 2200 B.c., a period corresponding to the Early Bronze Age. This period also corresponds with the early dynastic period in Egypt and the development of major centers of civilization in Mesopotamia. During the Early-Bronze-Age occupation of Bab edh-Dhra there are three major subphases. The first of these (EB I) lasted from 3150 to 3000 B.c. This period of settlement precedes the construction of the fortified town. The construction and occupation of the fortified town occurred between 3000 and 2350 B.C. (EB 11-111).The town was destroyed a t the end of this period but the site continued to be used until 2200 B.C. (EB IV). During the EB 589 590 DONALD J. ORTNER 1 subphase the burials, typically, were secondary and were placed in underground shaft tombs. Primary burial in charnel houses is primarily associated with the occupation of the fortified town. After the destruction of the town, burial was in underground tombs. The skeletal material in this report is exclusively from the Early Bronze I shaft tombs. The shaft tombs were prepared by excavating a shaft about one meter in diameter and one to two meters deep. In the wall near the bottom of the shaft one or more entryways, about one-half meter square, would be excavated and behind this a round or oblong chamber was dug about two meters in diameter and one meter in height. Tomb gifts, primarily pottery, would be placed on the periphery of the tomb chamber with skulls arranged to the left of a central long-bone pile. An average of three skeletons would be placed in each chamber. The entryway would be sealed and apparently the shaft was backfilled after all the chambers had been used. MATERIALS AND METHODS During the excavations of the cemetery a t Bab edh-Dhra in 1977 29 chambers containing human remains were excavated. On the basis of the work completed thus far, a total of 92 individuals was buried in these tomb chambers. Skeletal remains in four o f these chambers contained lesions of interest to the paleopathologist. It should be emphasized, however, that the skeletal remains were generally in a poor state of preservation and although the count of individuals is probably close to reality, it is possible that some pathological material was not recovered. The teeth were in particularly poor condition. Very often the crowns had been sheared off postmortem a t the cemento-enamel junction. It was generally possible to determine the broad categories of age for each skeleton on the basis of gross observation. More precise estimates of age must await more adequate reconstruction and histological analysis of long-bone sections. The categories were infant, encompassing the time period from birth to one year of age, child (subadult) from 1year of age to 18 years of age and, adult 18 years of age and older. The choice of 18 years as the upper limit for childhood is somewhat unconventional but reflects the realities of working with fragmentary and fragile specimens. Most of the epiphyses of the major long bones begin to fuse by 18. The basioccipital synchondrosis fuses a t approximate- ly 18 years and the third molar erupts a t about the same age. These features frequently can be evaluated in poorly preserved skeletons where more precise determination of age a t earlier. perhaps more appropriate, ages is more difficult. OBSERVATIONS We recovered very little evidence of trauma. One possible example was found in tomb chamber A80N. This chamber had been partially silted in. The skeletal remains were poorly preserved and difficult to recover. The specimen in question consists of the proximal half of a left, adult humerus. The articular surface is flattened and has considerable development of osteoarthritis on the periphery of the joint snrface (fig. 1).The joint surface itself is irregular with some porosity in the central portion of the surface. The position of the humeral head relative to the shaft is abnormal with the entire head displaced distally. There are two possible explanations for this abnormality. The first is a fracture through the neck of the humerus with subsequent fusion in the abnormal position. The second possibility is traumatic separation of the proximal epiphysis (epiphysiolysis) during the growth phase of the individual with subsequent healing in the distally displaced position. The neck of the humerus is unusually short suggesting a deficiency in growth. Such a deficiency would be expected with slipped epiphysis since t h e cartilage growth zone tends to remain with the epiphysis thus disrupting further growth of the humeral neck. For this reason slipped epiphysis rather than fracture would, in my judgment, be the preferred diagnosis. An example of trauma resulting from intentional violence is seen in the skull of an adult male of about 45 years of age at the time of death. This skeleton was found in shaft tomb chamber AlOON and, with the two children’s skeletons also found in the chamber, is the only example of primary burial found in any of the underground chambers excavated in 1977. The skull vault of the adult male has two depressed lesions. One of these was on the frontal bone, the other was located on the right parietal bone. Both lesions appear to be the result of a blow but showed extensive remodeling indicative of complete healing of the trauma. The two children whose skeletons were DISEASE AND MORTALITY IN EARLY BRONZE AGE 591 Fig. 1 The proximal left humerus (left) of a n adult from the A80N shaft tomb chamber in t h e Early Bronze Age cemetery a t Bab edh-Dhra, Jordan. This specimen is compared with a normal left humerus (right) from a modern dissecting room skeletal specimen. Note the distal deviation of the humeral head and the shortened neck of the humerus found in this chamber were about five and seven years of age a t death. The skull of the older child has a well circumscribed, lytic lesion on the sphenoid (fig. 2). The lesion involves the medial pterygoid lamina as well as the body of the sphenoid on the left side. The lesion measures 25 mm in its long axis, about 1 cm wide and 1 cm deep. The lesion is slightly porous but overall has a smooth compact bone surface indicative of a chronic condition. A tumor of the nasal passage is possible. Wells ('64: pp. 74-75) has noted the presence of tumors of the naso-pharynx in ancient skeletons. He also reports that malignant carcinoma of the naso-pharynx is the most common malignancy in children and teenagers in parts of Africa today. Strouhal ('76) has described similar neoplasms in Egyptian archeological skeletal remains. However, the circumscribed nature of the lesion in the child's skull from Bab edh-Dhra does not suggest an invasive malignancy. Another possible cause of this lesion is tuberculosis. Rokitansky (1855: p. 175) indicates that tuberculosis often affects the body of the sphenoid. In untreated cases of tuberculosis the highest mortality occurs about seven years of age, thus the age of this specimen is compatible with a diagnosis of tuberculosis. A documented case of tuberculosis in an 8year-old child shows a destructive lesion on the body of the sphenoid (fig. 3) in almost the identical place as the child from Bab edhDhra. This case is from the Pathology Museum a t the University of Strasbourg, France (Museum No. 5266). In addition to the lesion on the sphenoid, there are destructive lesions of the right frontal bone and left mastoid process. The lesion in the sphenoid body is less circumscribed than the lesion seen in the Bab edh-Dhra child. However, in my opinion, the lesion in the child's skull from Bab edh-Dhra is more compatible with a diagnosis of tuberculosis than malignant tumor. It may be no more than an interesting coincidence but the most obvious and dramatic pathological conditions found during our excavations in 1977 were from a single shaft tomb chamber A100E. A total of ten individuals were buried in this chamber. Four of these were infants. Of the remaining six individuals, three had skeletal lesions which probably would have produced noticeable effects during life. The first of these cases is a young male skeleton about 18 years of age. The morbid condition is limited to the lumbar vertebrae (fig. 4). All of these vertebrae show varying degrees of 592 DONALD J. ORTNER Fig. 2 The skull base of B 6 to 7-year-old child from the AlOON shaft tomb chamber in the Early Bronze Age Cemetery at Bab edh-Dhra, Jordan. Note the well circumscribed lytic lesion on the left portion of the sphenoid body (arrow). porosity on t h e bodies, however this condition is minimal on the first two vertebrae. The third lumbar vertebra has periosteal reactive bone on t h e anterior cortex of t h e body, particularly on t h e left side. The inferior portion of the fourth vertebral body is completely destroyed leaving only t h e superior surface and a portion of t h e left cortex. There is considerable formation of reactive bone on t h e remaining surfaces adjacent to t h e disk and there is a cloaca through t h e remnant of the left cortex of the body. The exposed surface of t h e cancellous bone is somewhat scalloped. The almost complete destruction of the vertebral body would have resulted in kyphosis in t h e living individual. The fifth lumbar vertebra has considerable periosteal, reactive bone and a large osteophyte on t h e antero-superior, left portion of t h e body. There is no evidence of disease on the transverse or spinous processes. The sacrum is normal except for almost complete spina bifida occulta. The destructive nature of t h e morbid process on the fourth lumbar vertebra, with minimal bony reaction and healing, is strongly suggestive of tuberculosis. Differential diagnosis would include consideration of osteomyelitis, brucellosis, mycotic infections and Echinococcus infestation. Of these additional possibilities extensive destruction of a vertebral body resulting in collapse and kyphosis is rare except for osteomyelitis. In osteomyelitis, spinous and transverse processes are often involved. The morphology and distribution of t h e lesions favors a diagnosis of tuberculosis. Derry, ('38: p. 198) suggests t h e existence of tuberculosis in ancient Egypt by 3300 B.C. However, t h e first firm evidence of tuberculosis is reported by Smith and Ruffer ('10) in a n Egyptian mummy dated to t h e twenty-first DISEASE AND MORTALITY I N EARLY BRONZE AGE 593 Fig. 3 The skull base of a n 8-year-old child from the Pathology Museum a t t h e University of Strasbourg, France (Museum No. 5'266). The lesions on the skull are attributed to tuberculosis. Note t h e lytic lesion on the left portion of'the sphenoid body (arrow) dynasty (ca. 1000 B c 1. Morse e t al. ('64) reviewed several possible cases of bone tuberculosis in ancient Egyptian material. Certainly the young male skeleton from Rab edh-Dhra represents one of the earliest, possible cases of tuberculosis. An adult female skeleton also from shaft tomb chamber AlOOE shows evidence of osteomyelitis and osteoporosis. Pubic symphysis morphology suggests a n age in excess of 50 years. All of t h e bones are abnormally light. The sacrum, for example, weighs 42 grams while another sacrum, almost identical in size and from t h e same tomb chamber, weighs 68 grams. This suggests a n abnormal reduction in bone mass of about 35%.The gross size and shape of t h e vertebrae and pelvis are normal although there is a slight bulge in the pelvic canal from bone remodeling induced by t h e pressure of the femoral heads. The cortical surface of t h e pelvic bones have patches of porous bone, particularly in areas adjacent to muscle or ligament attachments. Although the long bones are less severely affected, roentgen films of the humeri show cortical thinning and loss of density characteristic of osteoporosis. A section of t h e midshaft of t h e right femur reveals considerable porosity of the compacta near t h e endosteal surface. There is no evidence of abnormal osteoclastic resorption as would be expected if t h e abnormal loss of bone density were due to hyperparathyroidism. In modern clinical practice abnormal loss of bone density (osteoporosis) is a well-known clinical syndrome and is most frequent in post-menopausal women. Its cause is not known but the syndrome is associated with diminished estrogen secretions. Post-menopausal osteoporosis would be the preferred diagnosis for t h e loss of bone mass in the adult female skeleton from tomb A100E. In addition to osteoporosis, t h e skeleton also exhibits lesions which are a response to infec- 594 DONALD J. ORTNER Fig. 4 A left lateral view of the lumbar vertebrae of a young adult skeleton from the AlOOE shaft tomb chamber in the Early Bronze Age Cemetery a t Bab edh-Dhra, Jordan. The body of the fourth vertebra has largely been destroyed. There is a sinus through the remnant of the cortical wall on the left side of this vertebra (arrow). The fourth and fifth vertebrae are not fused. tion. The lesions are particularly pronounced on the left tibia and fibula which are fused between the distal joint surfaces. On the anterior portion of the distal ends of both these bones there is a large, circumscribed lesion of periosteal reactive bone (fig. 5 ) . This bone is a reaction to an overlying skin ulcer. In addition, the right tibia, fibula and femur show evidence of reactive bone suggestive of a disseminated osteomyelitis. The focus for this dissemination could have been the skin ulcer but i t is also possible that the ulcer was a complication of osteomyelitis. Krogman (‘40: p. 46) describes a fused left tibia, fibula and talus from a male skeleton dated between 3000 and 2000 B.C. and excavated from the prehistoric site of Tepe Hissar in Iran. Krogman suggested arthritis or osteomyelitis as possible causes. There was no sequestrum. His figure 3d shows the anterior view of the specimen and indicates that trauma might be con- sidered as well. There is no evidence of ulcer in the figure. The third example of skeletal pathology from shaft tomb chamber AlOOE is found in the skeleton of an adult male who was a t least 50 years of age. The skeleton is normal except for the bones of the right hip and the presence of separate neural arches on the fourth and fifth lumbar vertebrae. The acetabulum is enlarged and shallow with considerable osteoarthritis on the periphery of the joint (fig. 6). The corresponding head of the femur is enlarged. There are two defects on the joint surface of the femoral head. On the anterior, inferior surface there is a curved depression about one centimeter wide and two centimeters in length. The lesion is porous but well circumscribed indicating a longstanding condition. The arch of the curve corresponds t o t h e curve of the anterior edge of the acetabular rim and i t seems likely that the surface of DISEASE AND MORTALITY IN EARLY BRONZE AGE 595 Fig. 5 The anterior view of the distal, fused tibia and fibula of an adult Female probably over 50 years of age found in shaft tomb chamber AlOOE in the cemetery a t Bab edh-Dhra, Jordan. Note the large, oval, circumscribed area of reactive bone on both the tihia and fibula (arrows) resulting from the bony reaction to an overlying ulcer the femoral head frequently articulated with the rim. The second defect is a deep but rather narrow groove in the posterior, inferior surface of the joint. The groove begins a t the pit for the ligamentum teres and continues posteriorly through the boundary of the joint surface. This defect is due to abnormal pressure on the joint surface by the ligamenturn teres perhaps during dislocation. Another possibility is that the ligamentum teres was abnormally elongated during dislocation. When the head was in the normal anatomical position the excess portions of the ligament would be pressed between the joint surfaces. There is increased surface irregularity and a slight groove in the corresponding joint surface of the acetabulum. The morphology of the components of this joint clearly indicate chronic antero-superior dislocation of the hip. Whether this is due to a congenital problem or trauma is not clear. Arguing in favor of a traumatic origin is the fact t h a t the left hip is normal. However, there is no evidence of trauma and the acetabulum is shallow which favors a diagnosis of congenital hip dislocation. In my opinion the evidence would favor the later interpretation. A careful demographic analysis of the skeletal material from Bab edh-Dhra must await a more careful sorting and reconstruction of the skeletal remains. For the present, a preliminary analysis of the skeletal material from Early Bronze I shaft tombs reveals that, of the 92 individuals recovered from the tomb chambers, 56 (61%)were adults 18 years of age or older, 28 (30%)were between 1and 18 years of age, and eight 19%) were between birth and one year of age. Angel ('76) found a similar distribution of deaths in Early Bronze Age skeletons from Karatas in Turkey. In a sample 596 DONALD J. ORTNER Fig. 6 The skeletal components of the right hip from an adult, male skeleton over 50 years of age from shaft-tomb chamber AlOOE in the cemetery a t Bab edh-Dhra, Jordan. Note the enlarged but shallow acetabulum and the t w o grooves in the articular surface of the femoral head (arrows). of 584 individuals, 34 (6%)were less than one year of age, 160 (27%)were between 1 and 14 years of age and 390 (67%)were 14 years of age or older. Angel uses a lower age limit for the subadult age range (14 versus 18 years) than I have used. This partially explains the differences in the subadult and adult age categories between the two Early Bronze Age skeletal samples. Angel's study of Middle Bronze Age skeletons from Lerna, Greece ('71: p. 70) indicates t h a t almost 36%of the skeletons were infants. This is a much higher infant mortality than that found a t Bab edh-Dhra or Karatas. The problem with such comparisons is that one must assume that the same proportions of infants who die are buried in the cemeteries. Assuming that the differences in frequency of infants in the cemetery reflect differences in infant mortality a possible explanation for the Early Bronze I people of Bab edh-Dhra is that their more nomadic way of life meant less exposure to endemic infectious diseases prevalent in the later, more sedentary people of Lerna. CONCLUSIONS In spite of rather high (by modern, Western standards) subadult mortality (39%) a t Bab edh-Dhra it is clear that many of' the adults lived beyond 50 years. There is minimal evidence of disease in the skeletons. This is not surprising since most diseases do not affect the skeleton. Indeed, one of the paradoxes of skeletal paleopathology is the possibility that the lack of evidence of skeletal disease in a cemetery population may be indicative of diminished resistance to infectious disease. Individuals lacking evidence of skeletal disease may be dying of acute diseases or in the acute phase of chronic diseases. This possibility is based on the fact that skeletal reaction, particularly to infectious disease, occurs primarily when the individual's immune response is sufficiently adequate to insure survival beyond the acute phase of a disease. Evidence of tuberculosis in the skeleton from tomb AlOOE is of considerable interest for paleopathology and the history of disease. There are very few mummy or skeletal specimens of purported tuberculosis dat.ing any earlier in time. The presence of osteomyelitis in another skeleton from the same tomb chamber suggests the presence of organisms causing osteomyelitis by the Early Bronze Age and supports Jones' ('10: pp. 283, 287) observation that lesions in an ancient Nubian specimen were most likely due to osteomyelitis. On theoretical grounds Cockburn ('63: pp. 68-102) DISEASE AND MORTALITY IN EARLY BRONZE AGE has argued t h a t infectious diseases of today have a long history of association with man. The evidence in t h e Bab edh-Dhra skeletal remains provides evidence t h a t the history of some morbid conditions extends back at least t o the Early Bronze Age. ACKNOWLEDGMENTS I should like to acknowledge t h e generous cooperation of Drs. Walter E. Rast and R. Thomas Schaub, t h e co-directors of t h e expedition to Bab edh-Dhra. The Smithsonian Research Foundation, HrdliEka Fund, the American Schools of Oriental Research and the Jordanian Department of Antiquities provided support for t h e cemetery excavations in 1977. A note of appreciation also goes to Mrs. Katharine Holland for her assistance in typing t h e manuscript. The technical assistance of Mrs. Agnes Stix and Ms. Jacquin Schulz is also appreciated. LITERATURE CITED Angel, J. L. 1971 The People of Lerna. Smithsonian Institution Press, Washington, D.C. 597 _ _ 1976 Early Bronze Karatas people and their cemeteries. American J. Archaeo., 80: 385-391. Cockburn, A. 1963 The Evolution and Eradication of Infectious Diseases. The Johns Hopkins Press, Baltimore. Derry, D. E. 1938 Pott’s disease in ancient Egypt. Medical Press and Circular 197 (Old Series): 196-199. Jones, F. W. 1910 General pathology, fractures and dislocations in human remains. In: Archeological Survey of Nubia. Report for 1907-1908, No. 2, Cairo. Krogman, W. M. 1940 The skeletal and dental pathology of an early Iranian site. Bulletin of the History of Medicine, 8: 28-48. Lapp, P. W. 1968 Bab edh-Dhra tomb 76 and Early Bronze I in Palestine. Bulletin of the American Schools of Oriental Research, 189: 12-41. McNeill, W. H. 1977 Plagues and People. Anchor Press, Garden City. New York. Morse, D., U. H. Brothwell and P. J . Ucko 1964 Tubercu~ losis in ancient Egypt. American Review of Respiratory Diseases, 90: 524-541. Rokitansky, K. 1855 A Manual of Pathological Anatomy, Vol. 3. Translated from the last German edition by Charles H. Moore. Blanchard and Lea, Philadelphia. Smith, C . E., and M. A. Ruffer 1910 Pottsche Krankheit a n einer Aegyptischen Mumie aus der Zeit der 21 Dyuastie (um 1000 V. Chr.). In: Zur Historischen Biologic der Krankheitseneger. K. Sudhoff, ed. Leipzig, 2: 9-16. Strouhal, E. 1976 Tumors in the remains of ancient Egyptians. Am. J. Phys. Anthrop.. 45: 613-620. Wells, C. 1964 Bones, Bodies and Disease. Frederick A. Praeger, New York and Washington.