Tuberculosis and leprosy: Evidence for interaction of disease • 29 



of convenience and that the evidence, constraints, and hy- 

 potheses could equally be drawn from other regions of the 

 world in which the two diseases coexisted in antiquity. 



Probably the earliest evidence of tuberculosis in Britain is 

 of Roman date from Cirencester (Wells 1982:181; Manches- 

 ter and Roberts 1987). During the succeeding centuries, the 

 prevalence of tuberculosis increased, upon the evidence of 

 skeletal specimens (Manchester and Roberts 1987). Unfortu- 

 nately it is impossible from skeletal evidence alone to assess 

 the absolute prevalence of the disease. The diagnostic criteria 

 for tuberculosis in skeletal remains are woefully inadequate, 

 the disease being diagnosed only at an advanced stage of 

 osseous involvement. The rate of skeletal involvement in 

 relation to the overall prevalence of tuberculosis in antiquity 

 is not known, and it is not justifiable to assume, unequivo- 

 cally, that this was the same in antiquity as it is today, al- 

 though this is likely. Neither is it possible at present from 

 osteoarcheological specimens to determine the primary site 

 of involvement, pulmonary or gastrointestinal. 



During the reign of Edward the Confessor, a ritual was 

 introduced for the cure of King's Evil. King's Evil was the 

 name applied to cervical lymphadenitis. Although cervical 

 lymphadenitis is of multiple etiology, tuberculous lymph- 

 adenitis secondary to initial tonsillar or pulmonary infection 

 was a prominent cause in the prechemotherapeutic era. Tu- 

 berculous cervical lymphadenitis is traditionally equated 

 with King's Evil. It may be significant, in epidemiological 

 terms of primary site involvement, that this practice was 

 introduced at the very time that urban development was a 

 phenomenon and when movement of peoples in market trad- 

 ing was becoming established. Clearly, Touching for the 

 King's Evil was of no anti-infective therapeutic value what- 

 soever, but the practice was probably of considerable spir- 

 itual and psychological benefit to the recipient, to say noth- 

 ing of his or her financial improvement thereby! Introduction 

 of this practice in England, and also in continental Europe at 

 a similar time, around the late lOth or early 1 Ith century, 

 suggests that the disease was widely known, of increasing 

 incidence, and sociocconomically significant. During the ad- 

 vancing Middle Ages, the practice continued and the number 

 of patients touched increased. 



By the mid 17th century it was recorded in the London 

 Bills of Mortality that, in years free of plague, 20% of all 

 deaths in the city were due to consumption (Clarkson 

 1975:39). Although there was no knowledge of bacteriology 

 and no autopsy confirmation of diagnosis, the clinical fea- 

 tures of advancing tuberculosis were doubtless known. Pro- 

 gressive untreated pulmonary tuberculosis, alternatively 

 known as consumption or phthisis, presents with intractable 

 cough, dyspnea, hemoptysis, and progressive emaciation. 

 There can have been little confusion with nontuberculous 

 pneumonia, and it is unlikely that carcinoma of the bronchus 

 was a common disease. It is probable therefore that tuber- 

 culosis was, indeed, a common cause of death in 17th cen- 

 tury urban centers. 



Zagreb Paleopathology Symp. 1988 



In terms of polity there was, in contrast to leprosy, no 

 segregation of the consumptive. Tuberculous individuals do 

 not exhibit the physical mutilations of leprosy, there are no 

 religious overtones associated with the disease, and presum- 

 ably the infective nature was not suspected. Therefore, the 

 expansion of medieval hospitals (v.i.) cannot be taken as 

 evidence of an increasing incidence of tuberculosis. Neither 

 was there legal enactment in respect of tuberculosis. 



It is unfortunate that the evidence for an increase in inci- 

 dence of tuberculosis during the advancing Middle Ages is 

 circumstantial, based on documents and traditions which do 

 not provide irrefutable proof of the disease. However, as 

 mentioned, in current paleopathological practice, the os- 

 teoarcheological diagnosis of tuberculosis is mainly made on 

 the spinal changes at an advanced stage of pathogenesis, at 

 which caseous destruction of vertebral bodies and subse- 

 quent collapse has occurred. Earlier stages of the disease are 

 rarely recognized and, as yet, diagnostic criteria for early 

 lesions have not been established. Within the framework of 

 constraint it has been remarked, in respect of prehistoric 

 Amerindian peoples that "if a contagious disease like tuber- 

 culosis was present in overcrowded prehistoric populations, 

 . . . then there should be many more cases than there have 

 been found to date" (Morse 1978). Such statements reinforce 

 the overwhelming need to establish criteria for the diagnosis 

 of skeletal tuberculosis at early stages of pathogenesis in 

 osteoarcheological contexts. Also, because the osteomyelitic 

 and septic arthritic lesions in tuberculosis are metastatic 

 changes from the initial site, it is not possible to establish the 

 incidence and changing pattern of primary pulmonary and 

 primary gastrointestinal tuberculosis. Such a facility would 

 be of immense value in the paleoepidemiology of the disease. 

 The considerations of rib lesions by Kelley and Micozzi 

 ( 1984) may be a pointer in this differentiation, but the lesions 

 described and also observed by Manchester and Roberts 

 (1987) are probably the sequel of empyema which may have 

 causes additional to pulmonary tuberculosis. 



Notwithstanding these constraints of evidence, it seems 

 certain that tuberculosis as a human disease was present in 

 Britain at least by the Roman period, that it increased in 

 prevalence throughout the Anglo-Saxon period, and that the 

 incidence rate increased further during the post-Norman 

 Conquest period. The disease did not effectively become 

 controlled until the introduction of sanatoria and, particular- 

 ly, the advent of antituberculous chemotherapy in the 20th 

 century. 



The rising incidence rate in the post-Norman Conquest 

 period may be related to urban development and to popula- 

 tion movement and aggregation consequent upon regular 

 market development in the medieval period. A detailed ex- 

 amination of these paleodemographic changes is beyond the 

 scope of this paper, but, in similar vein, it is noted by Allison 

 (1979) that tuberculosis in Peruvian mummies was associ- 

 ated, in increasing prevalence, with the development of ur- 

 ban centers. 



