28 • Keith Manchester 



dependent upon contact with a fellow human with open in- 

 fectious disease. Pulmonary tuberculosis is, therefore, a 

 crowd disease of population density dependence. It is, of 

 course, possible, particularly within the confmes of the com- 

 munal animal-human ionghouse, for pulmonary infection via 

 inhalation of M. hovis to develop from intimate contact with 

 an "open" cattle infection. It is further acknowledged that 

 post-primary infection, irrespective of primary focus, may 

 be achieved by ingestion or inhalation. But, as already 

 stated, it is the primary infection, and the immunity devel- 

 oped thereby, which is significant to the arguments of this 

 paper. It is proposed therefore that, in antiquity, there was a 

 baseline of M. bovis primary infection which was sporadic 

 and totally independent of human population size. In addi- 

 tion, as primary disease, and superimposed as post-primary 

 disease, there was M. tuberculosis infection. This was de- 

 pendent upon population density, and followed and was a 

 con.sequence of urbanization and aggregation of peoples in 

 trade. It is unfortunate but, notwithstanding the pulmonary 

 tuberculous interpretations of rib lesions by Kelley and 

 Micozzi (1984), paleopathological differentiation of pulmo- 

 nary and gastrointestinal disease cannot, as yet, be made. 

 The above comments on the archaic implications of M. bovis 

 and M. tuberculosis have not, therefore, been investigated or 

 proven. 



SOCIOECONOMY 



Both tuberculosis and leprosy are diseases associated, in 

 general terms, with poverty, poor nutrition, and poor general 

 health status. Badger (1964:73) remarks that, in leprosy, "the 

 greatest prevalence has been, and remains, among peoples of 

 low economic status, with inadequate housing etc., which 

 leads to crowding and intimate contact." In the paleopathol- 

 ogy of tuberculosis, a demonstration of these factors has yet 

 to be made. In the paleopathology of leprosy, M0ller- 

 Christensen (1978: 1 17) reported that 69.7% of leprous skel- 

 etons from Naestved exhibited cribra orbitalia, while only 

 20.2% of contemporaneous nonleprous skeletons from 

 <€beIholt exhibited the lesion. The work of Stuart-Macadam 

 (1982) has indicated that cribra orbitalia is the manifestation 

 of anemia in infancy. The inference therefore from M0ller- 

 Christensens findings is that the leprous inmates of the 

 Nifistved leprosarium were from an anemic, nutritionally de- 

 prived section of medieval society. The possibility of chronic 

 intestinal parasitic infestation in infancy contributing to this 

 anemia may also suggest a poor general health status and 

 level of poverty. Further work on cribra orbitalia, porotic 

 hyperostosis, and latrine deposits of medieval lazar houses is 

 needed. 



History 



Although, within the remit of this paper, it is necessary to 

 consider only those regions in which leprosy and tuberculosis 



were coexistent in antiquity, it is appropriate to review the 

 earliest history and development of these two infectious dis- 

 eases of mankind. The development and prevalence of en- 

 demic infectious disease within a species may have relevance 

 to a developing innate immunity and to acquired immunity 

 within a population. 



Both leprosy and tuberculosis are relative newcomers to 

 the spectrum of human disease, and tuberculosis, in historic 

 terms, is the older of the two. 



TUBERCULOSIS 



The earliest evidence of tuberculosis as a human disease is 

 from the fourth millennium B.C., and consists of osteological 

 and iconographic specimens. A Neolithic skeleton of this 

 period from Italy exhibits spinal osteolytic lesions compat- 

 ible with a diagnosis of osseous tuberculosis (Formicolaetal. 

 1987). A figurine exhibiting angular kyphosis and features 

 suggestive of the cachexia of advanced consumption has 

 been described from fourth millennium Egypt (Morse et al. 

 1964). Other pre-Dynastic figurines with angular kyphosis 

 are known, but documentary records from the early Near 

 East do not contain descriptions suggestive of tuberculosis. 

 The Semitic Code Laws of Hammurabi of Babylon, the 

 Ebers Papyrus (Mercer 1964), and the medical Papyri (Cave 

 1939) do not record disease compatible with tuberculosis. 

 Further eastern Mediterranean examples of skeletal tuber- 

 culosis are known (Ortner 1979), and from the first millen- 

 nium B.C. tuberculosis has been identified in mummified 

 remains from Egypt. 



Further east, documentary records suggestive of tuber- 

 culosis are found in India of second millennium B.C. date, 

 and Mesopotamia of first millennium B.C. date. Suzuki 

 (1985) has described skeletal lesions from protohistoric 

 Japan. 



Although not within the discussion of this paper, it is of 

 interest and probable historic significance that the earliest 

 world evidence of animal domestication is from the eastern 

 Mediterranean, some three millennia before the earliest 

 world evidence of tuberculosis. 



Away from the Mediterranean littoral, the earliest Euro- 

 pean evidence of tuberculosis is a skeleton exhibiting spinal 

 lesions of Potts' disease, and dated to third/second millen- 

 nium B.C. from Denmark (Sager et al. 1972). A Neolithic 

 skeleton from Heidelberg has also been diagnosed as tuber- 

 culous on recognition of possible spinal lesions (Bartels 

 1907), but doubt has recently been cast on this diagnosis. 



However, for the purposes of this paper examining a possi- 

 ble relationship between leprosy and tuberculosis, it is appro- 

 priate and necessary to consider in detail only one geographic 

 area where the two diseases coexisted and in which their 

 history is adequately known. For these reasons and for the 

 convenience of the author, detailed examination of the later 

 history will be confined to Britain. It is acknowledged, of 

 course, that this somewhat blinkard microcosmic view is one 



Zagreb Falecpiitholotty S\mp. I9S8 



